Medicare Physician & Other Practitioners - by Provider Data Dictionary
National Provider Identifier
National Provider Identifier (NPI) for the rendering provider on the claim. The provider NPI is the numeric identifier registered in NPPES.
Last Name/Organization Name of the Provider
When the provider is registered in NPPES as an individual (entity type code='I'), this is the provider's last name. When the provider is registered as an organization (entity type code = 'O'), this is the organization name.
First Name of the Provider
When the provider is registered in NPPES as an individual (entity type code='I'), this is the provider's first name. When the provider is registered as an organization (entity type code = 'O'), this will be blank.
Middle Initial of the Provider
When the provider is registered in NPPES as an individual (entity type code = 'I'), this is the provider's middle initial. When the provider is registered as an organization (entity type code = 'O'), this will be blank.
Credentials of the Provider
When the provider is registered in NPPES as an individual (entity type code='I'), these are the provider's credentials. When the provider is registered as an organization (entity type code = 'O'), this will be blank.
Gender of the Provider
When the provider is registered in NPPES as an individual (entity type code='I'), this is the provider's gender. When the provider is registered as an organization (entity type code = 'O'), this will be blank.
Entity Type of the Provider
Type of entity reported in NPPES. An entity code of 'I' identifies providers registered as individuals and an entity type code of 'O' identifies providers registered as organizations.
Street Address 1 of the Provider
The first line of the provider's street address, as reported in NPPES.
Street Address 2 of the Provider
The second line of the provider's street address, as reported in NPPES.
State Abbreviation of the Provider
The state where the provider is located, as reported in NPPES. The fifty U.S. states and the District of Columbia are reported by the state postal abbreviation.
State FIPS Code of the Provider
FIPS code for rendering provider's state.
Zip Code of the Provider
The provider's zip code, as reported in NPPES.
RUCA Code of the Provider
Rural-Urban Commuting Area Codes (RUCAs), are a Census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area and Urban Cluster definitions in combination with work commuting information to characterize all of the nation's Census tracts regarding their rural and urban status and relationships. The Referring Provider ZIP code was cross walked to the United States Department of Agriculture (USDA) 2010 Rural-Urban Commuting Area Codes.
RUCA Description
Description of Rural-Urban Commuting Area (RUCA) Code
Country Code of the Provider
The country where the provider is located, as reported in NPPES. The country code will be 'US' for any state or U.S. possession. For foreign countries (i.e., state values of 'ZZ').
Provider Type of the Provider
Derived from the provider specialty code reported on the claim. For providers that reported more than one specialty code on their claims, this is the specialty code associated with the largest number of services.
Medicare Participation Indicator
Identifies whether the provider participates in Medicare and/or accepts assignment of Medicare allowed amounts. The value will be 'Y' for any provider that had at least one claim identifying the provider as participating in Medicare or accepting assignment of Medicare allowed amounts within HCPCS code and place of service. A non-participating provider may elect to accept Medicare allowed amounts for some services and not accept Medicare allowed amounts for other services.
Number of HCPCS
Total number of unique HCPCS codes.
Number of Medicare Beneficiaries
Total Medicare beneficiaries receiving services from the provider. The beneficiary counts reported in the demographic sub-groups (i.e., age, sex, race and entitlement) may not aggregate to the 'Number of Unique Beneficiaries' due to the suppression of beneficiaries fewer than 11 within the demographic sub-groups. In addition, a small percentage of beneficiaries are reflected in the "Number of Unique Beneficiaries" but are not reflected in the beneficiary demographic information due to the lack of demographic information available at the time of reporting.
Number of Services
Total provider services.
Total Submitted Charge Amount
The total charges that the provider submitted for all services.
Total Medicare Allowed Amount
The Medicare allowed amount for all provider services. This figure is the sum of the amount Medicare pays, the deductible and coinsurance amounts that the beneficiary is responsible for paying, and any amounts that a third party is responsible for paying.
Total Medicare Payment Amount
Total amount that Medicare paid after deductible and coinsurance amounts have been deducted for all the provider's line item services.
Total Medicare Standardized Payment Amount
Total amount that Medicare paid after deductible and coinsurance amounts have been deducted for the line item service and after standardization of the Medicare payment has been applied. Standardization removes geographic differences in payment rates for individual services, such as those that account for local wages or input prices and makes Medicare payments across geographic areas comparable, so that differences reflect variation in factors such as physicians' practice patterns and beneficiaries' ability and willingness to obtain care.
Drug Suppress Indicator
Identifies whether the utilization, cost and payment information associated with HCPCS codes for drug services as listed on the Medicare Part B Drug Average Sales Price (ASP) list have been suppressed. An '*' identifies that the suppressed information is based on fewer than 11 beneficiaries and a '#' identifies that the information has been counter suppressed to prevent the re-calculation of information suppressed due to fewer than 11 beneficiaries. For example, if the information associated with Drug services has been suppressed because fewer than 11 beneficiaries received these services from a provider, then the information associated with Medical services must also be suppressed so that the information associated with Drug services cannot be recalculated by subtracting the Medical values from the provider's overall values.
Number of HCPCS Associated With Drug Services
Total number of HCPCS codes for drug services, as defined from the Medicare Part B Drug ASP File.
Number of Medicare Beneficiaries With Drug Services
Total Medicare beneficiaries receiving drug services, as defined from the Medicare Part B Drug ASP File.
Number of Drug Services
Total drug services, as defined from the Medicare Part B Drug ASP File.
Total Drug Submitted Charge Amount
The total charges that the provider submitted for drug services, as defined from the Medicare Part B Drug ASP File.
Total Drug Medicare Allowed Amount
The Medicare allowed amount for drug services, as defined from the Medicare Part B Drug ASP File. This figure is the sum of the amount Medicare pays, the deductible and coinsurance amounts that the beneficiary is responsible for paying, and any amounts that a third party is responsible for paying.
Total Drug Medicare Payment Amount
Total amount that Medicare paid after deductible and coinsurance amounts have been deducted for all the provider's line item drug services, as defined from the Medicare Part B Drug ASP File.
Total Drug Medicare Standardized Payment Amount
Total amount that Medicare paid after deductible and coinsurance amounts have been deducted for the line item drug service, as defined from the Medicare Part B Drug ASP File and after standardization of the Medicare payment has been applied. Standardization removes geographic differences in payment rates for individual services, such as those that account for local wages or input prices and makes Medicare payments across geographic areas comparable, so that differences reflect variation in factors such as physicians' practice patterns and beneficiaries' ability and willingness to obtain care.
Medical Suppress Indicator
Identifies whether the utilization, cost and payment information associated with HCPCS codes for Medical (non-ASP) services have been suppressed. An '*' identifies that the suppressed information is based on fewer than 11 beneficiaries and a '#' identifies that the information has been counter suppressed to prevent the re-calculation of information suppressed due to fewer than 11 beneficiaries. For example, if the information associated with Medical (non-ASP) services has been suppressed because fewer than 11 beneficiaries received these services from a provider, then the information associated with Drug services must also be suppressed so that the information associated with Medical services cannot be recalculated by subtracting the Drug values from the provider's overall values.
Number of HCPCS Associated With Medical Services
Total number of HCPCS codes associated with medical (non-ASP) services.
Number of Medicare Beneficiaries With Medical Services
Total Medicare beneficiaries receiving medical (non-ASP) services.
Number of Medical Services
Total medical (non-ASP) services.
Total Medical Submitted Charge Amount
The total charges that the provider submitted for medical (non-ASP) services.
Total Medical Medicare Allowed Amount
The Medicare allowed amount for medical (non-ASP) services. This figure is the sum of the amount Medicare pays, the deductible and coinsurance amounts that the beneficiary is responsible for paying, and any amounts that a third party is responsible for paying.
Total Medical Medicare Payment Amount
Total amount that Medicare paid after deductible and coinsurance amounts have been deducted for all of the provider's line item medical (non-ASP) services.
Total Medical Medicare Standardized Payment Amount
Total amount that Medicare paid after deductible and coinsurance amounts have been deducted for the line item medical (non-ASP) service, as defined from the Medicare Part B Drug ASP File and after standardization of the Medicare payment has been applied. Standardization removes geographic differences in payment rates for individual services, such as those that account for local wages or input prices and makes Medicare payments across geographic areas comparable, so that differences reflect variation in factors such as physicians' practice patterns and beneficiaries' ability and willingness to obtain care.
Average Age of Beneficiaries
Average age of beneficiaries. Beneficiary age is calculated at the end of the calendar year or at the time of death.
Number of Beneficiaries Age Less 65
Number of beneficiaries under the age of 65. Beneficiary age is calculated at the end of the calendar year or at the time of death.
Number of Beneficiaries Age 65 to 74
Number of beneficiaries between the ages of 65 and 74. Beneficiary age is calculated at the end of the calendar year or at the time of death.
Number of Beneficiaries Age 75 to 84
Number of beneficiaries between the ages of 75 and 84. Beneficiary age is calculated at the end of the calendar year or at the time of death.
Number of Beneficiaries Age Greater 84
Number of beneficiaries over the age of 84. Beneficiary age is calculated at the end of the calendar year or at the time of death.
Number of Female Beneficiaries
Number of female beneficiaries.
Number of Male Beneficiaries
Number of male beneficiaries.
Number of Non-Hispanic White Beneficiaries
Number of non-Hispanic white beneficiaries. Race/ethnicity information is based on the variable RTI_RACE_CD from the CMS CCW enrollment database. The RTI_RACE_CD variable is based upon a validated algorithm that uses Census surname lists and geography to improve the accuracy of race/ethnicity classification, particularly for those who are Hispanic or Asian/Pacific Islanders.
Number of Black or African American Beneficiaries
Number of non-Hispanic black or African American beneficiaries. Race/ethnicity information is based on the variable RTI_RACE_CD from the CMS CCW enrollment database. The RTI_RACE_CD variable is based upon a validated algorithm that uses Census surname lists and geography to improve the accuracy of race/ethnicity classification, particularly for those who are Hispanic or Asian/Pacific Islanders.
Number of Asian Pacific Islander Beneficiaries
Number of Asian Pacific Islander beneficiaries. Race/ethnicity information is based on the variable RTI_RACE_CD from the CMS CCW enrollment database. The RTI_RACE_CD variable is based upon a validated algorithm that uses Census surname lists and geography to improve the accuracy of race/ethnicity classification, particularly for those who are Hispanic or Asian/Pacific Islanders.
Number of Hispanic Beneficiaries
Number of Hispanic beneficiaries. Race/ethnicity information is based on the variable RTI_RACE_CD from the CMS CCW enrollment database. The RTI_RACE_CD variable is based upon a validated algorithm that uses Census surname lists and geography to improve the accuracy of race/ethnicity classification, particularly for those who are Hispanic or Asian/Pacific Islanders.
Number of American Indian/Alaska Native Beneficiaries
Number of American Indian or Alaska Native beneficiaries. Race/ethnicity information is based on the variable RTI_RACE_CD from the CMS CCW enrollment database. The RTI_RACE_CD variable is based upon a validated algorithm that uses Census surname lists and geography to improve the accuracy of race/ethnicity classification, particularly for those who are Hispanic or Asian/Pacific Islanders.
Number of Beneficiaries With Race Not Elsewhere Classified
Number of beneficiaries with race not elsewhere classified.
Number of Beneficiaries With Medicare & Medicaid Entitlement
Number of Medicare beneficiaries qualified to receive Medicare and Medicaid benefits. Beneficiaries are classified as Medicare and Medicaid entitlement if in any month in the given calendar year they were receiving full or partial Medicaid benefits.
Number of Beneficiaries With Medicare Only Entitlement
Number of Medicare beneficiaries qualified to receive Medicare only benefits. Beneficiaries are classified as Medicare only entitlement if they received zero months of any Medicaid benefits (full or partial) in the given calendar year.
Percent (%) of Beneficiaries Identified With Atrial Fibrillation
Percent of beneficiaries meeting the CCW chronic condition algorithm for atrial fibrillation. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Alzheimer's Disease or Dementia
Percent of beneficiaries meeting the CCW chronic condition algorithm for atrial fibrillation. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Asthma
Percent of beneficiaries meeting the CCW chronic condition algorithm for Asthma. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Cancer
Percent of beneficiaries meeting the CCW chronic condition algorithms for cancer. Includes breast cancer, colorectal cancer, lung cancer and prostate cancer. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Heart Failure
Percent of beneficiaries meeting the CCW chronic condition algorithm for heart failure. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Chronic Kidney Disease
Percent of beneficiaries meeting the CCW chronic condition algorithm for chronic kidney disease.To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Chronic Obstructive Pulmonary Disease
Percent of beneficiaries meeting the CCW chronic condition algorithm for chronic obstructive pulmonary disease. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Depression
Percent of beneficiaries meeting the CCW chronic condition algorithm for depression. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Diabetes
Percent of beneficiaries meeting the CCW chronic condition algorithm for diabetes. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Hyperlipidemia
Percent of beneficiaries meeting the CCW chronic condition algorithm for hyperlipidemia. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Hypertension
Percent of beneficiaries meeting the CCW chronic condition algorithm for hypertension. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Ischemic Heart Disease
Percent of beneficiaries meeting the CCW chronic condition algorithm for ischemic heart disease. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Osteoporosis
Percent of beneficiaries meeting the CCW chronic condition algorithm for osteoporosis. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Rheumatoid Arthritis / Osteoarthritis
Percent of beneficiaries meeting the CCW chronic condition algorithm for rheumatoid arthritis/osteoarthritis. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Schizophrenia / Other Psychotic Disorders
Percent of beneficiaries meeting the CCW chronic condition algorithm for schizophrenia and other psychotic disorders. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Percent (%) of Beneficiaries Identified With Stroke
Percent of beneficiaries meeting the CCW chronic condition algorithm for stroke. To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75%. Information on source data is available from the CMS Chronic Conditions Warehouse (CCW).
Average HCC Risk Score of Beneficiaries
Average Hierarchical Condition Category (HCC) risk score of beneficiaries.
Medicare Part D Prescribers - by Provider and Drug Data Dictionary
Prescriber NPI
National Provider Identifier (NPI) for the performing provider on the claim.
PrescriberLast Name / Organization Name
When the provider is registered in NPPES as an individual (Prscrbr_Ent_Cd = "I"), this is the provider's last name. When the provider is registered as an organization (Prscrbr_Ent_Cd = "O"), this is the organization name.
Prescriber First Name
When the provider is registered in NPPES as an individual (Prscrbr_Ent_Cd = "I"), this is the provider's first name. When the provider is registered as an organization (Prscrbr_Ent_Cd = "O"), this will be blank.
Prescriber City
The city where the provider is located, as reported in NPPES.
Prescriber State
The state where the provider is located, as reported in NPPES. The fifty U.S. states and the District of Columbia are reported by the state postal abbreviation.
Prescriber State FIPS Code
FIPS code for referring providers state.
Provider Specialty Type
Derived from the Medicare provider/supplier specialty code reported on the NPI's Part B claims. For providers that have more than one Medicare specialty code reported on their claims, the Medicare specialty code associated with the largest number of services is reported. Where a prescriber's NPI did not have associated Part B claims, the taxonomy code associated with the NPI in NPPES is mapped to a Medicare specialty code using an external crosswalk published here: https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/medicare-provider-and-supplier-taxonomy-crosswalk. For any taxonomy codes that could not be mapped to a Medicare specialty code, the taxonomy classification description from the National Uniform Claim Committee (NUCC) taxonomy code set is used. For more information on the NUCC taxonomy code set, please visit: http://www.nucc.org
Source of Provider Specialty
A flag that indicates the source of the Prscrbr_Type.
Brand Name
Brand name (trademarked name) of the drug filled.
USAN Generic Name - Short Version
A term referring to the chemical ingredient of a drug rather than the trademarked brand name under which the drug is sold.
Number of Medicare Part D Claims, Including Refills
The number of Medicare Part D claims. This includes original prescriptions and refills. Aggregated records based on Tot_Clms fewer than 11 are not included in the data file.
Number of Standardized 30-Day Fills, Including Refills
The aggregate number of Medicare Part D standardized 30-day fills. The standardized 30-day fill is derived from the number of days supplied on each Part D claim divided by 30. Standardized 30-day fill values less than 1.0 were bottom-coded with a value of 1.0 and standardized 30-day fill values greater than 12.0 were top-coded with a value of 12.0.
Number of Day's Supply for All Claims
The aggregate number of day's supply for which this drug was dispensed.
Aggregate Cost Paid for All Claims
The aggregate drug cost paid for all associated claims. This amount includes ingredient cost, dispensing fee, sales tax, and any applicable vaccine administration fees and is based on the amounts paid by the Part D plan, Medicare beneficiary, government subsidies, and any other third-party payers.
Number of Medicare Beneficiaries
The total number of unique Medicare Part D beneficiaries with at least one claim for the drug. Counts fewer than 11 are suppressed and are indicated by a blank.
Reason for Suppression of GE65_Tot_Clms, GE65_Tot_30day_Fills, GE65_Tot_Drug_Cst and GE65_Tot_Day_Suply
A flag that indicates the reason the GE65_Tot_Clms, GE65_Tot_30day_Fills, GE65_Tot_Drug_Cst and GE65_Tot_Day_Suply variables are suppressed
Number of Claims, Including Refills, for Beneficiaries Age 65+
The number of Medicare Part D claims for beneficiaries age 65 and older. This includes original prescriptions and refills. A blank indicates the value is suppressed. See GE65_Sprsn_Flag regarding suppression of data.
Number of Standardized 30-Day Fills, Including Refills, for Beneficiaries Age 65+
The number of Medicare Part D standardized 30-day fills for beneficiaries age 65 and older. The standardized 30-day fill is derived from the number of days supplied on each Part D claim divided by 30. Standardized 30-day fill values less than 1.0 were bottom-coded with a value of 1.0 and standardized 30-day fill values greater than 12.0 were top-coded with a value of 12.0. If GE65_Tot_Clms is suppressed, this variable is suppressed. A blank indicates the value is suppressed. See GE65_Sprsn_Flag regarding suppression of data.
Aggregate Cost Paid for All Claims for Beneficiaries Age 65+
The aggregate total drug cost paid for all associated claims for beneficiaries age 65 and older. This amount includes ingredient cost, dispensing fee, sales tax, and any applicable vaccine administration fees and is based on the amounts paid by the Part D plan, Medicare beneficiary, government subsidies, and any other third-party payers. If GE65_Tot_Clms is suppressed, this variable is suppressed. A blank indicates the value is suppressed. See GE65_Bene_Sprsn_Flag regarding suppression of data.
Number of Day's Supply for All Claims for Beneficaries Age 65+
The aggregate number of day's supply for which this drug was dispensed, for beneficiaries age 65 and older. If GE65_Tot_Clms is suppressed, this variable is suppressed. A blank indicates the value is suppressed. See GE65_Bene_Sprsn_Flag regarding suppression of data.
Reason for Suppression of GE65_Tot_Benes
A flag indicating the reason the GE65_Tot_Benes variable is suppressed.
Number of Medicare Beneficiaries Age 65+
The total number of unique Medicare Part D beneficiaries age 65 and older with at least one claim for the drug. A blank indicates the value is suppressed. See GE65_Bene_Sprsn_Flag regarding suppression of data.
