SEER-CAHPS: Medicare Claims Files

Although brief summaries are provided below for each Medicare fee-for-service (FFS) claims file type included in the SEER-CAHPS database, additional links with more details are provided below to the Centers for Medicare & Medicaid Services (CMS’s) Research Data Assistance Center (ResDAC) and Chronic Conditions Warehouse (CCW) websites. Investigators should note that given SEER-CAHPS privacy policies some variables, namely identifiers of persons and providers and geographical locations such as zip codes, have been encrypted.

For Medicare beneficiaries with fee-for-service (FFS) coverage, claims data are available for two cohorts: persons with and without cancer from 1999 – 2019 (see Summary Table of Available Data). Beginning October 1, 2015, the coding system for diagnosis codes and procedure codes was switched from ICD-9 to ICD-10.

The Medicare claims files provided as part of SEER-CAHPS are described below and reflect input from staff at NCI and CMS.

Medicare Provider Analysis and Review (MedPAR)

The MedPAR file includes all Part A short stay, long stay, and skilled nursing facility (SNF) bills for each calendar year. MedPAR contains one summarized record per admission. Each record includes up to 25 diagnoses (ICD9/ICD10) and 25 procedures ((ICD9/ICD10) provided during the hospitalization.

Researchers interested in only short-stay hospitalizations will need to subset the MedPAR file using the variable 'MedPAR short stay/long stay/skilled nursing facility (SNF) indicator code' located in column 106 ('S' = short stay, 'L' = long stay and 'N' = skilled nursing stay).

In almost all cases, a single MedPAR record reflects a summary of all care provided during an institutional stay. However, if the stay is long, there may be more than one claim per stay. This occurs most frequently for stays in SNFs as these often span several months. SNFs records often have no discharge date as persons remain in institutions beyond the period of Medicare coverage.

Several fields on the MedPAR file are not considered reliable:

• source of admission;
• discharge destination; and
• group health organization payment code.

View ResDAC’s MedPAR File Overview

View CCW’s MedPAR Record Layout and Data Dictionary

Carrier Claims (NCH)

Since 1991, the Center for Medicare & Medicaid Services (CMS) has collected physician/supplier (Part B) bills for 100 percent of all claims. These bills, known as the National Claims History (NCH) records, are largely from physicians although the file also includes claims from other non-institutional providers such as physician assistants, clinical social workers, nurse practitioners, independent clinical laboratories, ambulance providers, and stand-alone ambulatory surgical centers. The claims are processed by carriers working under contract to CMS. Each carrier claim must include a Health Care Procedure Classification Code (HCPCS) to describe the nature of the billed service. The HCPCS is composed primarily of CPT-4 codes developed by the American Medical Association, with additional codes specific to CMS. Each HCPCS code on the carrier bill must be accompanied by a diagnosis code (ICD9, ICD10), providing a reason for the service. In addition, each bill has the fields for the dates of service, reimbursement amount, encrypted provider numbers (e.g., UPIN, NPI), and beneficiary demographic data.

Carrier Claims Details:

• Carrier claims are non-institutional claims, however this does not mean that they are outpatient claims. Providers, such as physicians, can bill for services provided in the office, hospital, or other sites. To identify where the service is provided, one needs to assess the variable "line place of service", which specifies the place of service.
• There are three subfiles – base file, line file and demonstrations/innovations code file. The base file contains the overall claim level information (e.g., claim ID, beneficiary ID, claim type, referring physician, claim from date, claim through date, claim processing date, carrier number, claim payment amount, claim allowed charge amount, and diagnosis codes). The line file contains the individual line level information from the claims (e.g., the procedure codes with the diagnosis associated with the procedure, first and last expense dates, line allowed charge amount, line submitted charge amount, and performing provider identifier).
• There are two pairs of date fields. The fields "claim from" and "claim through" dates cover a period of service (usually but not always a single date of service), while the "line first expense date" and "line last expense date" reflect the specific day of service.
• For every billed procedure (using a HCPCS code), there should be a corresponding ICD-9 or ICD-10 diagnosis code (often called the line item diagnosis) that provides the reason for the billed service. In the case of lab tests, the diagnosis will often be XXOOO because the outside lab has no information from the physician about the reason for the test. In addition, the carrier claim contains space for 12 diagnoses, these are listed on the base file and are often referred to as the “header” diagnoses. These are not necessarily linked with any of the procedures on the claim but may reflect co-existing health conditions. The accuracy of the diagnoses on the carrier data has not been determined.
• Selected services may not appear in the carrier claims, even if they have been provided. For example, CMS pays physicians a fixed amount for surgeries, a payment practice known as bundling. As part of bundling, CMS expects that certain care will be included in the payment amount, such as the first one or two office visits following surgery or a biopsy just before surgery. Bundled services will not appear in the physician data. Interpretation of the rules on bundling varies by carrier.

View ResDAC’s Carrier (Fee-For-Service) File Overview

View CCW’s Medicare Claims Record Layout and Codebook

Outpatient Claims

The outpatient file contains Part B claims for 100 percent for each calendar year from institutional outpatient providers. Examples of institutional outpatient providers include hospital outpatient departments, rural health clinics, renal dialysis facilities, outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities, community mental health centers. In and out surgeries performed in a hospital will be in the hospital outpatient file, while bills for surgeries performed in freestanding surgical centers appear in the carrier claims, not in the outpatient file.

There are multiple parts to this file: base file, revenue center file, condition code file, occurrence code file, span code file, value code file, and demonstration/innovation code file.

Some of the information contained in this outpatient file includes diagnosis and procedure codes, dates of service, reimbursement amounts, facility provider number, revenue center codes and beneficiary demographic information. Although the outpatient file contains data fields for ICD-9 or ICD-10 procedure codes, the reporting of these codes has been sporadic since 2000 when CPT/HCPCS codes replaced ICD-9 procedure codes as the basis of billing the Centers for Medicare & Medicaid Services for outpatient procedures. Since 2004, services from the outpatient bill have been captured from CPT/HCPCS codes and from the revenue centers.

As with the carrier data, there may be multiple records for the same date of service. Additionally, data related to each revenue center on a claim are written to a separate record.

View ResDAC’s Outpatient File Overview

View CCW’s Medicare Claims Record Layout and Codebook

Home Health Agency (HHA)

The Home Health Agency file contains 100 percent of all claims for home health services. Some of the information contained in this file includes the number of visits, type of visit (skilled-nursing care, home health aides, physical therapy, speech therapy, occupational therapy, and medical social services), diagnosis (ICD-9 or ICD10 diagnosis), the dates of visits, reimbursement amount, HHA provider number, and beneficiary demographic information. An HHA bill may cover services provided over a period of time, not a single day.

There are multiple parts to this file: base file, revenue center file, condition code file, occurrence code file, span code file, value code file, and demonstration/innovation code file.

View ResDAC’s HHA File Overview

View CCW’s Medicare Claims Record Layout and Codebook

Hospice

The Hospice file contains claims data submitted by Hospice providers. Some of the information contained in this file includes the level of hospice care received (e.g., routine home care, inpatient respite care), terminal diagnosis (ICD-9 or ICD-10 diagnosis), the dates of service, reimbursement amount, Hospice provider number, and beneficiary demographic information.

There are multiple parts to this file: base file, revenue center file, condition code file, occurrence code file, span code file, value code file, and demonstration/innovation code file.

View ResDAC’s Hospice File Overview

View CCW’s Medicare Claims Record Layout and Codebook

Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) contains final action claims data submitted to Durable Medical Equipment Regional Carriers (DMERCs). Some of the information contained in this file includes diagnosis, (ICD-9 or ICD-10 diagnosis), services provided (HCFA Common Procedure Coding System (HCPCS) codes), dates of service, reimbursement amount, DME provider number, and beneficiary demographic information. Claims for DME services that are processed by a carrier will be found in the NCH file. Claims for DME services that are processed by DMERCs will be found in the DME file. For example, claims for oral equivalents of IV chemotherapies will be found in the DME file.

There are multiple parts to this file: base file, line file, and demonstration/innovation code file.

View ResDAC's DME File overview

View CCW’s Medicare Claims Record Layout and Codebook

Medicare Part D Data

In July 2006 Medicare coverage was expanded to include prescription drugs under Medicare Part D, Medicare beneficiaries can enroll in Part D, and either opt to pay the Part D premium out of pocket or have their premiums paid for them, such as for low-income persons receiving medical assistance from their state. The Part D data included in SEER-CAHPS begin in 2007.

There are multiple files that are associated with the Part D data:

• Part D Drug Event File (PDE) Documentation - This file includes all transactions covered by Medicare prescription drug plan for both Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug Plans (MA-PDs).
  • Drug Characteristic File - variables appended to the PDE that describe the drug listed (e.g., NDC, brand and generic name)
• Plan Characteristics File - contains Medicare Advantage plan and Prescription Drug Plan information separated into six subfiles: base/benefit file, premium file, cost sharing tier file, service area file, special needs plans file, and multi-year crosswalk file. The information in the Plan Characteristics File can be linked to the PDE and the MBSF files (using contract and plan identifiers) to assess for variation in utilization and costs by plan type.
  • NOTE: The Multi-year Crosswalk File allows the same contract-plan to be tracked across years (Part D: 2007+; Part C 2015+), because contract and plan identifiers can change on an annual basis. The relationship code and relationship description variables clarify if a contract-plan in the reference year is new, renewal, consolidation, or termination. This annual file will include encrypted identifiers for years prior to 2015 and unencrypted identifiers for 2015 and later.
  • NOTE: The Plan Bridge File provides a crosswalk between the encrypted and unencrypted contract and plan identifiers; in 2015, CMS began releasing unencrypted contract and plan identifiers.
  • NOTE: The Multi-year Crosswalk File and Plan Bridge File can be used together to track plans across time (e.g., if a plan used one, encrypted identifier in 2010 but then switched to a new plan identifier in 2011, use the annual Crosswalk File 2010-2011 to find that change. Then use the Plan Bridge File to link this encrypted plan identifier to its unencrypted plan identifier and then the annual Crosswalk File again to track the same plan after 2015.
• Formulary File Documentation - suite of three subfiles: formulary, excluded drug and Over the Counter Drug that contain information on how the plan covers the prescription drugs filled.
• Pharmacy Characteristics File Documentation - contains information about the pharmacy identified as the source of the drug for each PDE prescription fill record.
  • Pharmacy Bridge File - In 2014, CMS changed the pharmacy identifier included on the PDE, this file provides a crosswalk that allows tracking the same pharmacy across this transition year.
    • NOTE: Although one can track the same pharmacy over time, all pharmacy identifiers are encrypted.
• Prescriber Characteristics File Documentation - contains descriptive information for the prescriber identified in the PDE file.
  • Prescriber Bridge File - In 2014, CMS changed the Prescriber identifier included on the PDE from the CCW Prescriber ID to the National Provider ID (NPI), this file provides a crosswalk that allows tracking the same prescriber across this transition year.
    • NOTE: Although one can track the same prescriber over time, all prescriber identifiers are encrypted.
• Part D Medication Therapy Management (MTM) File Documentation - indicates whether a beneficiary is enrolled in MTM (e.g., additional service(s) to ensure the best therapeutic outcomes for patients) and the number of drug-therapy recommendations made.

View CCW’s Medicare Claims Record Layout and Codebook