Comparing payer-side transparency files with provider-side

[iseff]

Perhaps this is a silly question, but...

We do a lot of work with provider side transparency files, and we're excited to compare those with these payer-side files.

One obvious thing I can't seem to figure out is why each line in the payer-side only appears to have one code/code type. Whereas in the provider side, most items will have a procedure code AND revenue code, for instance.

I'm sure I'm missing something here, but any help would be appreciated in order to help compare these files.

Thanks.

[iseff]

Ping! Any thoughts on this?

[rakeshkatte]

Claims I have seen mostly fall into the 2 categories (I wouldn't say I have seen them all, so there might be other scenarios too): 1. If room and board days are on the claim, the pricing is done based on these instead of the cpt codes. 2. If non room and board rev codes are on the claim, then the pricing is done based on the cpt codes. But we have not seen examples where the combination gives a different pricing. That being said, the current schema would work. However, we do have scenarios where we would need a combination of ICD diag codes and cpts, but now we are having to add one of these codes into the generic "additional information" node to explain the pricing being published.

…

On Tue, 22 Mar 2022, 22:39 Ian Sefferman, ***@***.***> wrote: Ping! Any thoughts on this? — Reply to this email directly, view it on GitHub <#413 (comment)>, or unsubscribe <https://github.com/notifications/unsubscribe-auth/AIJ2FFOPPQ2PDFEC3IFPKVDVBH5ETANCNFSM5RDKSNSQ> . You are receiving this because you are subscribed to this thread.Message ID: <CMSgov/price-transparency-guide/repo-discussions/413/comments/2416446 @github.com>

[iseff]

Thanks, @rakeshkatte. On the provider side (hospital price transparency files), we see plenty of different prices based on revenue code and procedure code (CPT) combinations. So, interesting to see that you haven't noticed this.

In either case, how would the current schema work exactly? I'm trying to figure that piece out still. Thanks again for the help!