CMS Pub. 100-04, ch. 23, § 30.3.5

B3-4621

The following guidelines are used to create the pricing files.

1. Recommended Physical File Specifications-Magnetic Tape - Tape characteristics-9 track, 8 2” to 10 2”

reels with silver mylar reflector (standard reels) with write ring removed.

Parity – Odd

Recording Density - 6250 bytes per inch

Recording Code - Extended Binary Coded Decimal

File Label - IBM standard label. The tape must have an end of file mark. The first data record on the file

identifies the submitter and the receiver and serves the function of a file label.

Physical Record Length - 60 characters

Blocking Factor - 100 records per block

The external label on the reel must appear as:

From

To

Reel number HCPCS (see footnote (a) below for entry) number (the unique number by which the tape is

identified in your library).

Date (MMDDYYYY)

2. Record Specifications. The logical HCPCS record is made up of a series of 60 character physical records.

3. Blocking factor of 100 (100 records per data block).

4. Header Type Specifications

Field

No.

Field Name Size Picture Specification Field Remarks

1 Label 3 X(3) L See Footnote (b)

2 Filler 7 X(7) L

3 A/B MAC (B) # 5 9(5) L

4 Filler 1 X(1)

5 Interm. # 5 9(5) L

6 Filler 1 X(1) L

7 Date Fee Updated 8 X(8) L MMDDYYYY

8 Filler 22 X(22)

9 Date File Created 8 X(8) L MMDDYYYY

5. Detail Record

Field

No.

Field Name Size Picture Specification Field Remarks

1 HCPCS 5 X(5) L

2 Filler 2 XX L

3 Filler 2 XX L

4 Fee/CF/Prev. 7 9(5)V99 R See Footnote (c) for

applicable category

5 Fee 7 9(5)V99 R See Footnote (d)

6 Fee 7 9(5)V99 R See Footnote (e)

7 A/B MAC (B) # 5 X(5) L

8 Locality 2 99 L

9 Filler 23 X(23)

(a) Identify the type of information furnished:

• DME fee schedule (includes supplies, inexpensive/routinely purchased, frequency service, and

capped rental);

• Surgical Dressings;

• Prevailing charges applicable to hospice physician services;

• Lab fee schedule;

• Other diagnostic service prevailing charges;

• Oxygen fee schedule;

• Prosthetic/orthotic fee schedule (includes ostomy, tracheostomy, and urologicals);

• Radiology conversion factors;

• Portable radiology fee schedule; or

• Certified registered nurse anesthetist conversion factors.

(b) Show the label for category as:

• DME - durable medical equipment;

• S/D - surgical dressings;

• HPH - prevailing charges for pricing hospice physician services;

• LAB - laboratory;

• ODX - other diagnostic services;

• OXY - oxygen;

• P/O - prosthetic/orthotic;

• RAD - radiology;

• PRF - portable radiology; or

• CNA - certified nurse anesthetist.

(c, d, e) DME

(c) purchase new

(d) purchase used

(e) monthly rental

NOTE: When a HCPCS code has multiple fees, list all the fees. A/B MACs (HHH) are not able to accept

procedure codes with modifiers.

HPH

(c) locality prevailing charge for physician services

LAB

(c) fee schedule amount - 60%

(d) fee schedule amount - 62%

ODX

(c) locality prevailing charge amounts

OXY

(c) purchase new/purchased oxygen contents

(d) purchase used

(e) monthly rental

P/O

(c) purchase new

RAD

(c) conversion factors

NOTE: HCPCS codes are not necessary for radiology.

PRF

(c) fee schedule amount

CNA

(c) conversion factor - medically directed CRNA services

(d) conversion factor - non-medically directed CRNA services