Frequently Asked Questions

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FAQ

By Topic: Medicare Provider Utilization and Payment Data


Who pays the difference between what the provider charges and Medicare pays?
The provider has an agreement with Medic... (more)

How does Medicare pay for services delivered by non-participating providers?
For services and procedures performed by... (more)

What is the difference between “Total Charges” and “Total Payments”?
“Total Charges” ... (more)

In the Inpatient and Outpatient Charge Data, what is the difference between “Average Charges” and “Av...
“Average Charges” refers to what the... (more)

Where can I find the standard payment by HCPCS code to compare to the data in the Physician and Other Suppl...
For standard payment and allowed amou... (more)

Are the inpatient and outpatient charge data available for any additional APCs or DRGs?
Beginning with FY2014, the Inpatient PUF... (more)

Is it possible to obtain a list of hospitals classified as teaching and non-teaching by CMS?
CMS has established a list of teaching hospitals (hospitals ... (more)

What is CMS doing in addressing opioid overutilization, including in the Medicare Part D program?
Prescription drug... (more)

In the context of the inpatient charge data, what does a discharge mean?
The total discharges indicate the number of beneficiaries wh... (more)

Are any of the data suppressed in the inpatient and outpatient charge data?
Data was suppressed if the provider had 10 or fewer outpatie... (more)

Why does the average Medicare payment amount differ across NPIs for the same HCPCS code in the Physician an...
The data in the Physician and Other Supplier PUF is aggregat... (more)

What is the source for the Physician and Other Supplier PUF?
The data for the Physician and Other ... (more)

Is the allowed amount in the Physician and Other Supplier PUF the amount that a Medicare beneficiary actual...
No. This figure includes the amount Medi... (more)

My physician has two practice locations.  Can I use the Physician and Other Supplier PUF to figure out...
No, the Physician and Other Supplier PUF... (more)

If I publish findings from the Medicare Provider Utilization and Payment Data in medical journals do I need...
No, this data is public information a... (more)

Payments for services often include different components that vary by place of service, which of these comp...
The average_Medicare_payment_amt represe... (more)

What is the difference between “Medicare Payment Amount” and “Medicare Standard Payment Amount” in ...
“Medicare Payment ... (more)

What is the population included in the Part D Prescriber PUF?
The Part D Prescriber PUF includes data ... (more)

What do I do if I think I’ve identified fraud in the Physician and Other Supplier PUF?
CMS is committed to the prevention an... (more)

Does the total drug cost represent the amount that Medicare paid for the prescription in the Part D Prescri...
No. The total drug costs included in th... (more)

Can I access patient demographic information for any of the Medicare Provider Utilization and Payment Data ...
Patient demographic information and health characteristics a... (more)

Does anyone actually pay the submitted charges in the Physician and Other Supplier PUF?
In the private market, patients with com... (more)

In the Physician and Other Supplier PUF what is the definition for the bene_day_srvc_cnt variable?
The bene_day_srvc_cnt is the number of d... (more)

What is the population included in the Physician and Other Supplier PUF?
The Physician and Other Supplier PUF inc... (more)

How is therapy minutes defined on the “Therapy” table in the Skilled Nursing Facility PUF?
... (more)

What is the difference between “Medicare Payment Amount” and “Medicare Standard Payment Amount” in ...
... (more)

In the Home Health Agency PUF, why are “Total Charges” sometimes lower than “Total Payments”?
This is due to the nature of the home he... (more)

Does the Physician and Other Supplier PUF include non-physician practitioners, such as nurse practitioners?
Yes, you can filter on the provider_type... (more)

How did CMS calculate the values in the Physician and Other Supplier PUF?
The spending and utilization data in the... (more)

Can I link the Part D Prescriber PUF to other CMS releases or other public data?
Yes. However, when users attempt to lin... (more)

What are the diagnosis variables in the Hospice PUF?
The PUF contains 6 variables containing ... (more)

Do Medicare payments associated with drug services include payment of the drug and injection of the drug in...
Payment for part B drugs does not includ... (more)

Can I use the data in the Physician and Other Supplier PUF to create graphics, applications, or tools?
Yes, this data is public information.&nb... (more)

The documentation for the Physician and Other Supplier PUF indicates that for the "line_srvc_cnt" the metri...
Service counts may be calculated in different ways. For most... (more)

What are the “Total Days” and “Hospice Beneficiaries” variables in the Hospice PUF?
... (more)

What is the source for the Referring Provider DMEPOS PUF?
The primary data sou... (more)

Do the average submitted charges in the Physician and Other Supplier PUF for services delivered in a facili...
When services are delivered in a facility setting, Medicare ... (more)

The Part D opioid drug data only represents the physician’s Medicare patients – does it thus present an...
This is true. The data only represents o... (more)

How are averages calculated for the “Average Charge Amount”, “Average Payment Amount”, and “Avera...
The average payment ... (more)

Can I link the Physician and Other Supplier PUF to other data CMS releases or other public data?
When linking data from this file to othe... (more)

What are the definitions for the “Total Episodes” and “Distinct Users” variables in the Home Health...
“Total episodes”... (more)

What is the difference between “Medicare Payment Amount” and “Medicare Standard Payment Amount” in ...
“Medicare Payment Amount” is the actual amount that Medi... (more)

For each HCPCS code (particularly the ones that start with J for drugs), does the variable average_submitte...
The average submitted charge is derived ... (more)

Don’t physicians have a privacy interest in the data in the Physician and Other Supplier PUF?
Prior to deciding to release physicia... (more)

What data was used to populate the Part D Opioid Drug Mapping Tool?
The data used in this mapping tool is fr... (more)

What is the prescription opioid epidemic?
... (more)

Does the Hospice PUF contain information for beneficiaries in Medicare Advantage or Medicaid?
... (more)

Does the Physician and Other Supplier PUF contain information for beneficiaries in Medicare Advantage or Me...
... (more)

What is the interactive online Part D opioid drug mapping tool?
Centers for Medicare & Medicaid Serv... (more)

My data doesn’t appear correct in the Part D Prescriber PUF, what can I do?
Data in the Part D Prescriber PUF is pulled from numerous... (more)

Are methadone claims included in the Part D Opioid Mapping tool drug data?
The data for the Part D Opioid Mapping t... (more)

Does the Home Health Agency PUF contain information for beneficiaries in Medicare Advantage? What about Med...
No, the Home Health ... (more)

What are the site of service variables in the Hospice PUF?
The PUF contains 7 v... (more)

When I open the Physician and Other Supplier PUF in Excel, I get an error, why?
The Physician and Other Supplier PUF contains just over 9 million lines of data.... (more)

Why does the average Medicare payment amount differ across referring NPIs for the same HCPCS code in the Re...
The data in the Refe... (more)

Are any of the data suppressed in the Home Health Agency PUF data?
Data was suppressed ... (more)

Why hasn’t CMS included information on quality in the Physician and Other Supplier PUF?
CMS has started publishing quality of... (more)

Does the Skilled Nursing Facility PUF contain information for beneficiaries in Medicare Advantage or Medicaid?
... (more)

Why don’t you include “Allowed Charges” in the Home Health Agency PUF?
Home health services... (more)

Does the average Medicare payment amount field in the Physician and Other Supplier PUF need to be adjusted?
No, the average_Medicare_payment_amt rep... (more)

What are the definitions for the “Total Stays” and “Distinct Beneficiaries” variables in the Skille...
... (more)

If I publish findings from the Home Health Agency PUF in medical journals do I need to obtain permission fr...
No, this data is pub... (more)

What does it mean that my state has a higher or lower number/percentage of opioid prescriptions when compar...
When a state has a higher percentage tha... (more)

Does the Part D Prescriber PUF contain information for beneficiaries in Medicare Advantage?
Yes, the Part D Prescriber PUF was developed using claims fr... (more)

Are any of the data suppressed in the Skilled Nursing Facility PUF data?
Data was suppressed ... (more)

Can a beneficiary be listed in more than one chronic condition indicator per row?
Yes, a beneficiary may have multiple chronic conditions and may be listed in mor... (more)

In the Physician and Other Supplier PUF how are averages calculated for the average_Medicare_allowed_amt, a...
The average payment ... (more)

How are averages calculated for the “Average Charge Amount”, “Average Allowed Amount”, “Average P...
... (more)

Are any of the data suppressed in the Hospice PUF data?
Hospice providers who had 10 or fewer hospice beneficiaries ... (more)

Where can I find the standard payment by HCPCS code to compare to the data in the Referring Provider DMEPOS...
For standard payment and allowed amount ... (more)

My physician has two practice locations. Can I use the Referring Provider DMEPOS PUF to figure out the tota...
No, the Referring Provider DMEPOS PUF do... (more)

How are you protecting beneficiary privacy in the Physician and Other Supplier PUF?
CMS takes beneficiary privacy very serio... (more)

In the Physician and Other Supplier PUF what is the definition for the "line_srvc_cnt" variable?
The "line_srvc_cnt" reflects the number of services provided... (more)

Is the allowed amount in the Referring Provider DMEPOS PUF the amount that a Medicare beneficiary actually ...
No. This figure includes the amount Medi... (more)

How were hospice beneficiaries’ diagnoses determined in the Hospice PUF?
The diagnosis variables are mutually exclusive at the provider level, a beneficiary will only be cou... (more)

If I publish findings from the Skilled Nursing Facility PUF in medical journals do I need to obtain permiss...
... (more)

How did CMS calculate the values in the Referring Provider DMEPOS PUF?
The spending and utilization data in ... (more)

What are you doing to protect beneficiary privacy in the Part D Prescriber PUF?
CMS is committed to protecting the privacy of Medicare benef... (more)

Don’t physicians and other healthcare professionals have a privacy interest in the data in the Referring ...
Prior to deciding to release physician a... (more)

Can “Hospice Beneficiaries” be summed across providers or states for a total count of distinct hospice ...
No, hospice beneficiaries cannot be summed across providers ... (more)

If I publish findings from the Hospice PUF in medical journals do I need to obtain permission from CMS?
No, this data is public information and users are free to us... (more)

Does anyone actually pay the submitted charges in the Referring Provider DMEPOS PUF?
In the private market, patients with comprehensive coverage ... (more)

What do I do if I think I’ve identified fraud in the Referring Provider DMEPOS PUF?
CMS is committed to the prevention and d... (more)

Can I link the Referring Provider DMEPOS PUF to other data CMS releases or other public data?
When linking data from this file to othe... (more)

Can “Distinct Beneficiaries” be summed across providers or RUGs for a total count of distinct skilled n...
No, beneficiaries ca... (more)

Why is “Total Stays” only included on the Provider table but not the other tables in the Skilled Nursin...
“Total Stays” is only included on th... (more)

Can the “Total Days” and “Hospice Beneficiaries” variables in the Hospice PUF be used to calculate ...
Total days and distinct hospice beneficiaries cannot be used to calculate length of stay in hospice ... (more)

What is the population included in the Referring Provider DMEPOS PUF?
The Referring Provid... (more)

Does the Referring Provider DMEPOS PUF include non-physician practitioners, such as nurse practitioners?
Yes, you can filter on the referring_pro... (more)

Are consumers’ clinical data subject to privacy and security protections in the Part D Opioid Drug Mappin...
The data set is privacy-protected and there is no beneficiary information contai... (more)

How was site of hospice services determined in the Hospice PUF?
The site of service variables are mutually exclusive at the provider level, a beneficiary will only ... (more)

When I open the Referring Provider DMEPOS PUF in Excel, I get an error, why?
The Referring Provider DMEPOS PUF contai... (more)

In the Referring Provider DMEPOS PUF how are averages calculated for the avg_supplier_Medicare_allow_amt, a...
The average payment and charge variables... (more)

How are you protecting beneficiary privacy in the Referring Provider DMEPOS PUF?
CMS takes beneficiary privacy very serio... (more)

Can I use the data in the Referring Provider DMEPOS PUF to create graphics, applications, or tools?
Yes, this data is public information.... (more)

Does the Referring Provider DMEPOS PUF contain information for beneficiaries in Medicare Advantage? What ab...
No, the Referring Provider DMEPOS PUF on... (more)

Why hasn’t CMS included information on quality in the Referring Provider DMEPOS PUF?
CMS has started publishing quality-of-ca... (more)

In the Referring Provider DMEPOS PUF what is the definition for the line_srvc_cnt variable?
The line_srvc_cnt reflects the number of... (more)

The documentation for the Referring Provider DMEPOS PUF indicates that for the line_srvc_cnt the metrics us...
Service counts may be calculated in diff... (more)

Does the average Medicare payment amount field in the Referring Provider DMEPOS PUF need to be adjusted?
No, the avg_supplier_Medicare_pmt_amt re... (more)