CMS Pub. 100-06, ch. 9, § 30.2

Summarizes claim data and other information by revenue code required for cost report settlement and CMS

reporting purposes. Time periods included on this report are specified by the user.

FREQUENCY: Upon request.

REPORT TYPES: A report is generated for each type. These report types are based on the first two digits

of the Bill Type code on the provider's claim form (CMS-1450). Report claims which cannot be mapped to

one of the report types are shown under "UNKNOWN REPORT TYPE."

Listed below are all known PS&R report types.

11A Inpatient – Part A (MSP-LCC)

Supplements report type 110.

For providers on PIP (Part A) the interim

payments included on the cost report will be

adjusted by the MSP-LCC amounts.

11I Inpatient – Part A Managed

Care (MSP-LCC)

Supplements report type 118.

For providers on PIP (Part A) the interim

payments included on the cost report will be

adjusted by the MSP-LCC amounts.

11J Inpatient – PPS Interim Bills

(MSP-LCC)

Supplements report type 119.

For providers on PIP (Part A) the interim

payments included on the cost report will be

adjusted by the MSP-LCC amounts.

11K Inpatient Rehab – PPS Interim

Bills

Summarizes Inpatient Part A hospital services

reimbursed under the Inpatient Rehabilitation

Facility PPS payment system that have been

billed on an interim basis (bill frequency code

of 2 or 3).

11R Inpatient Rehabilitation – Part

A

Summarizes Inpatient Part A hospital services

reimbursed under the Inpatient Rehabilitation

Facility PPS payment system.

110 Inpatient – Part A Summarizes Inpatient Part A hospital services.

Includes services reimbursed under cost,

TEFRA and Inpatient PPS payment systems.

118 Inpatient – Part A Managed

Care

Summarizes services billed under Part A for

Medicare managed care patients for purposes

of receiving reimbursement for DGME and

IME.

119 Inpatient – PPS Interim Bills Summarizes Inpatient Part A hospital services

reimbursed under the Inpatient PPS payment

system that have been billed on an interim

basis (bill frequency code of 2 or 3).

12A Inpatient – Part B (MSP-LCC)

Supplements report type 120.

For providers on PIP (Part A) the interim

payments included on the cost report will be

adjusted by the MSP-LCC amounts.

12C Inpatient – Part B VAC

(MSP-LCC)

Supplements report type 122.

For providers on PIP (Part A) the interim

payments included on the cost report will be

adjusted by the MSP-LCC amounts.

12F Inpatient – Part B Fee

Reimbursed (MSP-LCC)

Supplements report type.

For providers on PIP (Part A) the interim

payments included on the cost report will be

adjusted by the MSP-LCC amounts.

12P Inpatient Part B OPPS Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

12Z Ambulance Blend Effective

4/01/02

Summarizes hospital outpatient ambulance

services reimbursed under the ambulance fee

schedule blended payment, which is effective

for services provided On/after April 1, 2002.

120 Inpatient – Part B Accumulates data for services normally

covered under Part A that have become

covered under Part B. For reimbursement

purposes, Inpatient Part B and Outpatient Part

B are combined on the cost report.

122 Inpatient – Part B VAC Accumulates data applicable to vaccine

services reimbursed based on 100% of

reasonable cost. Data on this report is used to

complete the cost report.

125 Inpatient – Part B Fee

Reimbursed

Shows covered charges and reimbursement by

revenue code for fee reimbursed services (for

patients who have exhausted Part A benefits).

13A Outpatient – All Other (MSP-LCC)

Supplements report type 130.

13B Outpatient – Renal (MSP-LCC)

Supplements report type 131.

13C Outpatient – Part B 100%

(MSP-LCC)

Supplements report type 132.

13F Outpatient – Fee Reimbursed

(MSP-LCC)

Supplements report type 135. Covered charges

and reimbursement are shown by revenue

code for fee reimbursed services. Data also

represents MSP claims paid on Lower of Cost

or Charges (LCC) and considered settled at

the claim level.

13G O/P Other Diag. & Fee

Schedule After 9/90(MSP-LCC)

Supplements report type 136.

13H O/P Other Diag. & Fee

Schedule. Before 10/90(MSP-LCC)

Supplements report type 137.

13I O/P Radiology & Fee

Schedule After 9/89 (MSP-LCC)

Supplements report type 138.

13J O/P Rad & Fee Sch Pre 10/89

Or After 12/90(MSP-LCC)

Supplements report type 139.

13P Outpatient – OPPS Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

13Z Ambulance Blend Effective

04/01/02

Summarizes hospital outpatient ambulance

services reimbursed under the ambulance fee

schedule blended payment, which is effective

for services provided on/after April 1, 2002.

130 Outpatient – All

Other/Ambulance

Summarizes hospital outpatient data

reimbursed on a reasonable cost basis, for all

services other than diagnostic (see 136),

radiology (see 139) and ASC (see 831)

services. Also summarizes laboratory services

reimbursed on a fee schedule in a

supplemental report.

131 Outpatient – Renal Displays outpatient hospital ESRD service for

services prior to April 1, 1990.

132 Outpatient – Part B 100% Accumulates data applicable to vaccine

services reimbursed based on 100% of

reasonable cost. Data on this report is used to

complete the cost report.

135 Outpatient Fee Reimbursed Shows covered charges and reimbursement by

revenue code for fee reimbursed services

(Hospital Outpatient setting).

136 O/P Other Diag. & Fee

Schedule After 9/90

Summarizes all outpatient other diagnostic

services reimbursed in part based on a fee

schedule.

137 O/P Other Diag. & Fee

Schedule Before 10/90

Summarizes all outpatient other diagnostic

services reimbursed in part based on a fee

schedule.

138 Outpatient Radiology & Fee

Schedule After 9/89

Summarizes outpatient radiology services

reimbursed based on a fee schedule.

139 O/P Rad & Fee Sch Pre 10/89

And/Or After 12/90

Summarizes outpatient radiology services

reimbursed based on a fee schedule.

14A Outpatient / Other (MSP-LCC)

Supplements report type 140.

14C Outpatient/Other Vaccines

(MSP-LCC)

Supplements report type 142. This report

accumulates data applicable to vaccine

services reimbursed based on 100% of

reasonable cost. Data on this report is used to

complete the cost report.

14F Outpatient/Other

Mammography (MSP-LCC)

Supplements report type 145.

14P Outpatient/Other – OPPS Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

140 Outpatient/ Other – All Other Summarizes hospital other Part B data (bill

type 14x) reimbursed on a reasonable cost

basis.

142 Vaccines Accumulates data applicable to vaccine

services reimbursed based on 100% of

reasonable cost. Data on this report is used to

complete the cost report.

145 Outpatient/Other

Mammography/ Fee

Reimbursed

Shows covered charges and reimbursement by

revenue code for fee reimbursed services.

18A Swing Bed (MSP-LCC) Supplements report type 180.

180 Swing Bed Summarizes Swing Bed hospital services. A

supplement to this report accumulates data by

RUG category.

21A SNF -Inpatient – Part A

(MSP-LCC)

Supplements report type 210.

210 SNF -Inpatient – Part A Summarizes SNF Inpatient – Part A services.

22A SNF -Inpatient – Part B 100%

(MSP-LCC)

Supplements report type 220.

22C SNF – Inpatient – Part B

100% VAC (MSP-LCC)

Supplements report type 222.

22F SNF-Inpatient – Fee

Reimbursed (MSP-LCC)

Supplements report type 225. Covered charges

and reimbursement are shown by revenue

code for fee reimbursed services. Data also

represents MSP claims paid on Lower of Cost

or Charges (LCC) and considered settled at

the claim level.

22P SNF-Outpatient-OPPS

(Condition Code 07

W/Cast/Splint/Ant)

Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

22Z Ambulance Blend effective

04/02/02

Summarizes skilled nursing facility, outpatient

ambulance services reimbursed under the

ambulance fee schedule blended payment,

which is effective for services provided

on/after April 1, 2002.

220 SNF -Inpatient – Part B 100% Summarizes SNF Inpatient – Part B services.

222 SNF -Inpatient – Part B 100%

VAC

Accumulates data applicable to vaccine

services reimbursed based on 100% of

reasonable cost. Data on this report is used to

complete the cost report.

225 SNF -Inpatient – Fee

Reimbursed

Shows covered charges and reimbursement by

revenue code for fee reimbursed services.

23A SNF – Outpatient (MSP-LCC)

Supplements report type 230.

23C SNF – Outpatient VAC

(MSP-LCC)

Supplements report type 232.

23F SNF – Outpatient Fee

Reimbursed (MSP-LCC)

Supplements report type 235. Covered charges

and reimbursement are shown by revenue

code for fee reimbursed services. Data also

represents MSP claims paid on Lower of Cost

or Charges (LCC) and considered settled at

the claim level.

23P SNF-Outpatient-OPPS

(Condition Code 07

W/Cast/Splint/Ant)

Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

23Z Ambulance Blend effective

04/02/02

Summarizes skilled nursing facility, outpatient

ambulance services reimbursed under the

ambulance fee schedule blended payment,

which is effective for services provided

on/after April 1, 2002.

230 SNF – Outpatient Summarizes SNF outpatient services.

232 SNF – Outpatient VAC. Accumulates data applicable to vaccine

services reimbursed based on 100% of

reasonable cost. Data on this report is used to

complete the cost report.

235 SNF – Outpatient Fee

Reimbursed

Shows covered charges and reimbursement by

revenue code for fee reimbursed services.

24P SNF-Outpatient-OPPS

(Condition Code 07

W/Cast/Splint/Ant)

Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

32C Home Health – (MSP-LCC) OD44203 report number under report type

32A: Summarizes the Part B claims with a

plan of treatment that are subject to MSP-LCC

limitation. Services included on this report are

typically not subject to deductible or

coinsurance. Report was previously used in

cost reports ending prior to October 1, 2000,

and then only if the provider was reimbursed

under PIP method.

D45300 report number (which corresponds to

the OD44203 report): Summarizes visits and

census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 32A is NOT needed for cost

reporting purposes.

32M Home Health – (MSP-LCC) Supplements report type 329.

320 Home Health – Part B OD44203 report number under report type

320: Summarizes data included on home

health Part B claims with a plan of treatment

prior to implementation of home health PPS

(October 1, 2000). Services included on this

report are typically not subject to deductibles

or coinsurance.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 320 is NOT needed for cost

reporting purposes.

322 Home Health – Part B Summarizes Medicare Part B Requests for

Anticipated Payments (RAPs) activity. The

RAPs are not used in the cost report.

329 Home Health – Part B

Episode

OD44203 report number under report type

329: Summarizes data included on Part B

home health prospective payments episodes

covered under a signed plan of treatment. Part

B home health data is broken out into different

episodic units. Services included on this report

are typically not subject to deductibles or

coinsurance.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 329 is NOT needed for cost

reporting purposes.

33A Home Health – Part A (MSP-LCC)

OD44203 report number under report type

33A: Summarizes the Part A claims with a

plan of treatment that is subject to MSP-LCC

limitation. Services included on this report are

typically not subject to deductible or

coinsurance. Report was previously used in

cost reports ending prior to October 1, 2000,

and then only if the provider was reimbursed

under PIP method.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 33A is NOT needed for cost

reporting purposes.

33M Home Health – Part A (MSP-LCC)

Supplements report type 339.

330 Home Health – Part OD44203 report number under report type

330: Summarizes data included on home

health Part A claims with a plan of treatment

prior to implementation of home health PPS

(October 1 2000).

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 330 is NOT needed for cost

reporting purposes.

332 Home Health – Part A Summarizes Medicare Part A Requests for

Anticipated Payments (RAPs) activity. The

RAPs are not used in the cost report.

339 Home Health – Part A

Episode

OD44203 report number under report type

339: Summarizes data included on Part A

home health prospective payment episodes

covered under a signed plan of treatment. Part

A home health data is broken out into different

episodic units.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 339 is NOT needed for cost

reporting purposes.

34A Home Health – Part B (MSP-LCC)

Summarizes the Part B claims not under a plan

of treatment that is subject to MSP-LCC

limitation. Data found in this report are subject

to coinsurance and deductible.

34P HHA Outpatient-OPPS (Not

Hhpps)

Summarizes the Part B claims data not under a

signed plan of care that are reimbursed under

Outpatient PPS. Used in cost reports prior to

starting date of 10/1/00.

340 Home Health – Part B. (w/o a

plan of treatment)

Summarizes data included on Part B claims

without a signed plan of treatment. Services

included on this report are typically subject to

deductibles or coinsurance.

342 Home Health – Part B –

Vaccine

Summarizes Part B vaccine claim data that is

not reimbursed under OPPS.

345 Home Health – Part B –

Rehab

Summarizes the Part B therapy claims data

that was furnished on and after 1/1/99 and not

under a signed plan of care.

399 Home Health – Part A And

Part B Episode

Summarizes the home health episode data

from the 329 Home Health Part B Episode

report and the 339 Home Health Part A

Episode report.

410 Christian Science – Inpatient

– Part A

Summarizes the Medicare days, discharges,

charges, deductibles, coinsurance and net

reimbursement for a reporting period.

Christian Science facilities typically have

relatively low Medicare utilization and the

majority of their charges are for routine

inpatient care.

71A Clinic – Rural Health (MSP-LCC)

Supplements report type 710.

71C Clinic – Rural Health – 100%

(MSP-LCC)

Supplements report type 712.

71P Clinic-Rural Health-OPPS

(Condition Code 07)

Captures data from all lines that were paid

under OPPS including lines paid as ASC

services packaged with them. Effective with

services 8/1/00 and after.

710 Clinic – Rural Health Summarizes data for rural health clinic

services (bill type 71x) paid based on an all-inclusive rate.

712 Clinic – Rural Health – VAC Summarizes vaccine services provided by

rural health clinics.

72A Hosp. Based Or Ind. Renal

Dialysis Center (MSP-LCC)

Supplements report type 720.

72C Free Standing Renal Dialysis

100% – VAC (MSP-LCC)

Supplements report type 722.

720 Hosp. Based Or Independent.

Renal Dialysis Center

Summarizes data for renal dialysis centers

(bill type 72x) paid based on an all-inclusive

rate.

722 Free Standing Renal Dialysis

100% – VAC

Summarizes vaccine services provided by

Free Standing Renal Dialysis centers.

73A FQHC (MSP-LCC) Supplements report type 730.

73C FQHC-100% (MSP-LCC) Supplements report type 732.

73P FQHC-OPPS (Condition

Code 07)

Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

730 FQHC Summarizes data for Federally Qualified

Health Clinic services (bill type 73x) paid

based on an all-inclusive rate.

732 FQHC-VAC Summarizes vaccine services provided by

FQHC facilities.

74A Rehabilitation Facility (MSP-LCC)

Supplements report type 740.

74C Rehabilitation Facility-100%

(MSP-LCC)

Supplements report type 742.

74F Rehabilitation Facility-Fee

Reimbursed (MSP-LCC)

Supplements report type 745.

74P Rehabilitation Facility-OPPS

(Condition Code 07)

Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

740 Rehabilitation Facility Shows cost reimbursed data, if any, by

accommodation and ancillary service revenue

codes. Captures lines of claims paid under the

cost-reimbursed method for Outpatient Rehab

facilities-mainly services prior to 1/1/99. This

report is used to determine whether a provider

has either Low Utilization or No Medicare

Business for cost reporting.

No cost report is required for reporting periods

ending on or after July 1, 2003 [CMS Flash

Report – dated May 9, 2003].

742 Rehabilitation Facility-VAC Summarizes vaccine services provided by

CORF facilities.

745 Rehabilitation Facility-Fee

Reimbursed

Shows covered charges and reimbursement by

revenue code for fee reimbursed services.

75A CORF (MSP-LCC) Supplements report type 750.

75C CORF-100% (MSP-LCC) Supplements report type 752.

75F CORF-Fee Reimbursed

(MSP-LCC)

Supplements report type 755. Covered charges

and reimbursement are shown by revenue

code for fee reimbursed services. Data also

represents MSP claims paid on Lower of Cost

or Charges (LCC) and considered settled at

the claim level.

75P CORF-OPPS Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

750 CORF Shows cost reimbursed data, if any, by

accommodation and ancillary service revenue

codes. Captures lines of claims paid under the

cost-reimbursed method for Comprehensive

Rehab Facilities mainly services prior to

1/1/99. This report is used to determine

whether a provider has either Low Utilization

or No Medicare Business for cost reporting.]

No cost report is required for reporting periods

ending on or after April 1, 2001 [CMS Flash

Report – dated May 9, 2003].

752 CORF-VAC Summarizes vaccine services provided by

CORF facilities.

755 CORF-Fee Reimbursed Shows covered charges and reimbursement by

revenue code for fee reimbursed services.

76A Community Mental Health

Center (MSP-LCC)

Supplements report type 760.

76C Community Mental Health

Center-100% (MSP-LCC)

Supplements report type 762.

76F Community Mental Health

Center-Fee Reimbursement

(MSP-LCC)

Supplements report type 765. Covered charges

and reimbursement are shown by revenue

code for fee reimbursed services. Data also

represents MSP claims paid on Lower of Cost

or Charges (LCC) and considered settled at

the claim level.

76P CMHC-OPPS Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

760 Community Mental Health

Center

Captures lines of claims paid under the cost-reimbursed method for Community Health

Centers – mainly services prior to 8/1/00.

762 Community Mental Health

Center-VAC

Summarizes vaccine services provided by

Community Health Centers.

765 Community Mental Health

Center-Fee Reimbursed

Shows covered charges and reimbursement by

revenue code for fee reimbursed services.

81A Hospice – Non-Hospital

Based (MSP-LCC)

OD44203 report number under report type

81A: Summarizes the Non-Hospital based

(Free Standing) Hospice claims that are

subject to MSP-LCC limitation.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 81A is informational only.

81P Hospice – Non-Hospital

Based –OPPS (Condition

Code 07)

Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

810 Hospice – Non-Hospital

Based

OD44203 report number under report type

810: Summarizes the Non-Hospital based

(Free Standing) hospice claim data. May be

used in cost report.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 810 is informational only.

82A Hospice – Hospital Based

(MSP-LCC)

OD44203 report number under report type

82A: Summarizes the Hospital (provider)

based Hospice claims that are subject to the

MSP-LCC limitation.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 82A is informational only.

82P Hospice – Hospital Based-

OPPS (Condition Code 07)

Captures data from all lines of a claim that

were paid under OPPS including lines paid as

APC services packaged with them. Effective

with services 8/1/00 and after.

820 Hospice – Hospital Based OD44203 report number under report type

820: Summarizes the Hospital (provider)

based Hospice claim data. May be used in cost

report.

OD45300 report number (which corresponds

to the OD44203 report): Summarizes visits

and census per metropolitan statistical area

(MSA). The OD45300 report number under

report type 820 is informational only.

83A ASC And ASC Fee Schedule

(MSP-LCC)

Supplements report type 830.

83B ASC And ASC Fee Schedule

After 12/90 (MSP-LCC)

Supplements report type 831.

830 ASC And ASC Fee Schedule Summarizes all outpatient ambulatory surgical

services reimbursed in part based on HCPCS.

831 ASC And ASC Fee Schedule

After 12/90

Summarizes all outpatient ambulatory surgical

services reimbursed in part based on HCPCS.

85A CAH (MSP-LCC) Supplements report type 850.

85C CAH-100% (MSP-LCC) Supplements report type 852.

85F CAH-Fee

Reimbursed/Mammography

(MSP-LCC)

Supplements report type 855. Covered charges

and reimbursement are shown by revenue

code for fee reimbursed services. Data also

represents MSP claims paid on Lower of Cost

or Charges (LCC) and considered settled at

the claim level.

85Z CAH Ambulance Blend

Effective 04/01/02

Summarizes critical access hospital, outpatient

ambulance services reimbursed under the fee

schedule blended payment, which is effective

for services provided on/after April 1, 2002.

850 CAH Summarizes data for critical access hospital

services (bill type 85x) reimbursed on a cost

basis.

852 CAH-VAC Summarizes vaccine services provided by

critical access hospitals reimbursed on a

reasonable cost basis.

855 CAH-Fee

Reimbursed/Mammography

Shows covered charges and reimbursement by

revenue code for fee reimbursed services.

998 Hospital Outpatient – Part B Summarizes, by revenue code and report type,

the information that is printed on the various

outpatient report types. This report cannot be

used to complete the cost report.

999 All Report Types For

Provider

MSA/Beneficiary Census/Rev Visits report:

Summarizes the visits and census per

metropolitan statistical area (MSA). The

OD45300 report number under report type 999

for Home Health Agencies is used for cost

reporting periods ending before October 1,

2000.

The OD45300 report number under report

type 999 for hospice providers is

informational only.

OD

44215

DRG Summary Report Summarizes PPS data by DRGs. It is optional

and requested on demand.

NOTE: In all cases other than outpatient, the report type ties directly to the type of bill entered on the claim

(CMS-1450). For outpatient bills, the distinction is broken out further to identify the bills as All Other, Part

B 100 percent, renal bills, and ASC.