CMS Pub. 100-04, ch. 3, § 20.1.2.10

The following return codes are calculated by PRICER and passed back to the calling

program. Depending on the type of payment and case, return codes 30, 44, 33, 40 and 42

indicate that an outlier would be paid if the cost-to-charge ratio would rise by 20 percentage

points. If a provider(s) (CCR rises by 10 percentage points and) meets the criteria of

reconciliation, the CMS Central Office uses return codes 30, 44, 33, 40 and 42 to determine a

smaller pool of claims for reprocessing claims due to outlier reconciliation.

Acute Care

Return Code 00: Paid normal DRG payment.

Return Code 02: Paid normal DRG payment plus a cost outlier.

Return Code 14: Paid normal DRG payment with per diem days equal or greater than

geometric mean length of stay.

Return Code 16: Paid normal DRG payment plus a cost outlier with per diem days equal to

or greater than geometric mean length of stay.

Return Code 30: Paid normal DRG payment and indicates an outlier payment would be

necessary if the CCR would increase by 20 percentage points.

Return Code 44: Paid normal DRG payment with per diem days equal or greater than

geometric mean length of stay and indicates an outlier payment would be necessary if the

CCR would increase by 20 percentage points.

Transfer Cases

Return Code 03: Paid a per diem payment to the transferring IPPS hospital (when the patient

transfers to an IPPS hospital) up to and including the full DRG payment if the covered days

are less than the geometric mean length of stay for the DRG. If covered days equal or

exceed the geometric mean length of stay, the standard payment is calculated.

Return Code 05: Paid a per diem payment to the transferring IPPS hospital (when the patient

transfers to an IPPS hospital) up to and including the full DRG payment if the covered days

are less than the geometric mean length of stay for the DRG. If covered days equal or

exceed the geometric mean length of stay, the standard payment is calculated. Also indicates

case qualified for a cost outlier payment.

Return Code 06: Paid a per diem payment to the transferring IPPS hospital (when the patient

transfers to an IPPS hospital) up to and including the full DRG payment if the covered days

are less than the geometric mean length of stay for the DRG. If covered days equal or

exceed the geometric mean length of stay, the standard payment is calculated. Also indicates

provider refused cost outlier payment.

Return Code 33: Paid a per diem payment to the transferring IPPS hospital (when the patient

transfers to an IPPS hospital) up to and including the full DRG payment if the covered days

are less than the geometric mean length of stay for the DRG. If covered days equal or

exceed the geometric mean length of stay, the standard payment is calculated. Also indicates

an outlier payment would be necessary if the CCR increased by 20 percentage points.

Postacute Transfer Cases

Return Code 10: Makes payment to the transferring IPPS hospital (when the patient transfers

to a non-IPPS hospital) for postacute transfer DRGs (that have double the payment on the 1st

day for purposes of the postacute care transfer policy) as published in the annual IPPS Final

Rule. Will calculate a per diem payment based on the standard DRG payment if the covered

days are less than the geometric mean length of stay for the DRG. If covered days equal or

exceed the geometric mean length of stay the standard payment is also calculated. The cost

outlier portion of the payment is calculated if the adjusted charges on the bill exceed the

outlier threshold.

Return Code 12: Makes payment to the transferring IPPS hospital (when the patient transfers

to a non-IPPS hospital) for postacute transfer DRGs (that receive 50 percent of the

prospective payment on the 1st day of the stay for purposes of the postacute care transfer

policy) as published in the annual IPPS Final Rule. Will calculate a per diem payment based

on the standard DRG payment if the covered days are less than the geometric mean length of

stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the

standard payment is calculated. The cost outlier portion of the payment is calculated if the

adjusted charges on the bill exceed the outlier threshold.

Return Code 40: Makes payment to the transferring IPPS hospital (when the patient transfers

to a non-IPPS hospital) for postacute transfer DRGs (that have double the payment on the 1st

day for purposes of the postacute care transfer policy) as published in the annual IPPS Final

Rule. Will calculate a per diem payment based on the standard DRG payment if the covered

days are less than the geometric mean length of stay for the DRG. If covered days equal or

exceed the geometric mean length of stay, the standard payment is calculated. Also indicates

an outlier payment would be necessary if the CCR increased by 20 percentage points.

Return Code 42: Makes payment to the transferring IPPS hospital (when the patient transfers

to a non-IPPS hospital) for postacute transfer DRGs (that receive 50 percent of the

prospective payment on the 1st day of the stay for purposes of the postacute care transfer

policy) as published in the annual IPPS Final Rule. Will calculate a per diem payment based

on the standard DRG payment if the covered days are less than the geometric mean length of

stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the

standard payment is calculated. Also indicates an outlier payment would be necessary if the

CCR increased by 20 percentage points.