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Psychological Evaluation Template - Excel by slp21736

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									Medicare Cost Report Depatments Mapped to Standard Crosswalk Departments                                                                   Facility Specific Overrides

             Medicare Cost Report Departments                             Standard Crosswalk Department        Crosswalk Department List     Medicare Cost Report Department     Revenue Codes
       ANCILLARY SERVICE COST CENTERS
  37   Operating Room                                                10     Operating Room                 3     Labor and Delivery
  38   Recovery Room                                                 10     Operating Room                 6     Drugs
  39   Delivery Room and Labor Room                                   3     Labor and Delivery             7     Supplies and Equipment
  40   Anesthesiology                                                11     Anesthesia                     8     Therapy Services
  41   Radiology-Diagnostic                                          14     Radiology                      9     Inhalation Therapy
  42   Radiology-Therapeutic                                         14     Radiology                     10     Operating Room
  43   Radioisotope                                                  10     Operating Room                11     Anesthesia
  44   Laboratory                                                    13     Laboratory                    12     Cardiology
  45   PBP Clinical Laboratory Services-Prgm. Only                   13     Laboratory                    13     Laboratory
  46   Whole Blood & Packed Red Blood Cells                           6     Drugs                         14     Radiology
  47   Blood Storing, Processing, & Trans.                            6     Drugs                         15     IV Therapy
  48   Intravenous Therapy                                           15     IV Therapy                    17     Clinic
  49   Respiratory Therapy                                            9     Inhalation Therapy            18     ER
  50   Physical Therapy                                               8     Therapy Services              19     Observation
  51   Occupational Therapy                                           8     Therapy Services              20     Other Services
  52   Speech Pathology                                               8     Therapy Services
  53   Electrocardiology                                             12     Cardiology
  54   Electroencephalography                                        12     Cardiology
  55   Medical Supplies Charged to Patients                           7     Supplies and Equipment
  56   Drugs Charged to Patients                                      6     Drugs
  59   Other Ancillary (specify)                                     20     Other Services
       OUTPATIENT SERVICE COST CENTERS
  60   Clinic                                                        17     Clinic
  61   Emergency                                                     18     ER
  62   Observation Beds                                              19     Observation
  63   Other Outpatient Service (specify)                            20     Other Services




             7/20/2011 1:31 PM
             D:\Docstoc\Working\pdf\459c59f9-e44b-4ee9-b250-147812fc14dc.xls\ [Departments]                    Milliman                                                        Page 1 of 7
                                                                   Revenue Code Reference Table



                             RevCode                       Major Category Description                        Standard Crosswalk Department
                               250        Pharmacy-general classification                                           6 Drugs
                               251        Pharmacy-generic drugs                                                    6 Drugs
                               252        Pharmacy-nongeneric drugs                                                 6 Drugs
                               253        Pharmacy-take home drugs                                                  6 Drugs
                               254                                                                                  6 Drugs
                                          Pharmacy-drugs incident to other diagnostic service--subject to payment limit
                               255        Pharmacy-drugs incident to radiology--subject to payment limit            6 Drugs
                               256        Pharmacy-experimental drugs                                               6 Drugs
                               257        Pharmacy-non-prescription                                                 6 Drugs
                               258        Pharmacy-IV solutions                                                     6 Drugs
                               259        Pharmacy-other pharmacy                                                   6 Drugs
                               260        IV therapy-general classification                                       15 IV Therapy
                               261        IV therapy-infusion pump                                                15 IV Therapy
                               262        IV therapy-pharmacy services (eff 10/94)                                15 IV Therapy
                               263        IV therapy-drug supply/delivery (eff 10/94)                             15 IV Therapy
                               264        IV therapy-supplies (eff 10/94)                                         15 IV Therapy
                               269        IV therapy-other IV therapy                                             15 IV Therapy
                               270        Medical/surgical supplies-general classification-(also see 062X)          7 Supplies and Equipment
                               271        Medical/surgical supplies-nonsterile supply                               7 Supplies and Equipment
                               272        Medical/surgical supplies-sterile supply                                  7 Supplies and Equipment
                               273        Medical/surgical supplies-take home supplies                              7 Supplies and Equipment
                               274        Medical/surgical supplies-prosthetic/orthotic-devices                     7 Supplies and Equipment
                               275        Medical/surgical supplies-pace maker                                      7 Supplies and Equipment
                               276        Medical/surgical supplies-intraocular lens                                7 Supplies and Equipment
                               277        Medical/surgical supplies-oxygen-take home                                7 Supplies and Equipment
                               278        Medical/surgical supplies-other implants                                  7 Supplies and Equipment
                               279        Medical/surgical supplies-other devices                                   7 Supplies and Equipment
                               280        Oncology-general classification                                         20 Other Services
                               289        Oncology-other oncology                                                 20 Other Services
                               290        DME (other than renal)-general classification                             7 Supplies and Equipment
                               291        DME (other than renal)-rental                                             7 Supplies and Equipment
                               292        DME (other than renal)-purchase of new DME                                7 Supplies and Equipment
                               293        DME (other than renal)-purchase of used DME                               7 Supplies and Equipment
                               294        DME (other than renal)-related to and listed as DME                       7 Supplies and Equipment
                               299        DME (other than renal)-other                                              7 Supplies and Equipment
                               300        Laboratory-general classification                                       13 Laboratory
                               301        Laboratory-chemistry                                                    13 Laboratory
                               302        Laboratory-immunology                                                   13 Laboratory
                               303        Laboratory-renal patient (home)                                         13 Laboratory
                               304        Laboratory-non-routine dialysis                                         13 Laboratory
                               305        Laboratory-hematology                                                   13 Laboratory
                               306        Laboratory-bacteriology & microbiology                                  13 Laboratory
                               307        Laboratory-urology                                                      13 Laboratory
                               309        Laboratory-other laboratory                                             13 Laboratory
                               310        Laboratory pathological-general classification                          13 Laboratory
                               311        Laboratory pathological-cytology                                        13 Laboratory
                               312        Laboratory pathological-histology                                       13 Laboratory
                               314        Laboratory pathological-biopsy                                          13 Laboratory
                               319        Laboratory pathological-other                                           13 Laboratory
                               320        Radiology diagnostic-general classification                             14 Radiology
                               321        Radiology diagnostic-angiocardiography                                  14 Radiology
                               322        Radiology diagnostic-arthrography                                       14 Radiology
                               323        Radiology diagnostic-arteriography                                      14 Radiology
                               324        Radiology diagnostic-chest X-ray                                        14 Radiology
                               329        Radiology diagnostic-other                                              14 Radiology
                               330        Radiology therapeutic-general classification                            14 Radiology
                               331        Radiology therapeutic-chemotherapy injected                             14 Radiology
                               332        Radiology therapeutic-chemotherapy oral                                 14 Radiology
                               333        Radiology therapeutic-radiation therapy                                 14 Radiology
                               335        Radiology therapeutic-chemotherapy IV                                   14 Radiology
                               339        Radiology therapeutic-other                                             14 Radiology
                               340        Nuclear medicine-general classification                                 14 Radiology
                               341        Nuclear medicine-diagnostic                                             14 Radiology
                               342        Nuclear medicine-therapeutic                                            14 Radiology
                               349        Nuclear medicine-other                                                  14 Radiology
                               350        Computed tomographic (CT) scan-general-classification                   14 Radiology
                               351        CT scan-head scan                                                       14 Radiology
                               352        CT scan-body scan                                                       14 Radiology
                               359        CT scan-other CT scans                                                  14 Radiology
                               360        Operating room services-general classification                          10 Operating Room
                               361        Operating room services-minor surgery                                   10 Operating Room
                               362        Operating room services-organ transplant,-other than kidney             10 Operating Room
                               367        Operating room services-kidney transplant                               10 Operating Room

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[Path]459c59f9-e44b-4ee9-b250-147812fc14dc.xls\ [RevCodes]                      Milliman                                                       Page 2 of 7
                                                                   Revenue Code Reference Table



                             RevCode                       Major Category Description                         Standard Crosswalk Department
                               369        Operating room services-other operating room-services                    10 Operating Room
                               370        Anesthesia-general classification                                        11 Anesthesia
                               371        Anesthesia-incident to RAD and-subject to the payment limit              11 Anesthesia
                               372                                                                                 11 Anesthesia
                                          Anesthesia-incident to other diagnostic service-and subject to the payment limit
                               374        Anesthesia-acupuncture                                                   11 Anesthesia
                               379        Anesthesia-other anesthesia                                              11 Anesthesia
                               380        Blood-general classification                                             20 Other Services
                               381        Blood-packed red cells                                                   20 Other Services
                               382        Blood-whole blood                                                        20 Other Services
                               383        Blood-plasma                                                             20 Other Services
                               384        Blood-platelets                                                          20 Other Services
                               385        Blood-leukocytes                                                         20 Other Services
                               386        Blood-other components                                                   20 Other Services
                               387        Blood-other derivatives (cryopricipatates)                               20 Other Services
                               389        Blood-other blood                                                        20 Other Services
                               390        Blood storage and processing-general-classification                      20 Other Services
                               391        Blood storage and processing-blood-administration                        20 Other Services
                               399        Blood storage and processing-other                                       20 Other Services
                               400        Other imaging services-general classification                            14 Radiology
                               401        Other imaging services-diagnostic mammography                            14 Radiology
                               402        Other imaging services-ultrasound                                        14 Radiology
                               403        Other imaging services-screening mammography-(eff 1/1/91)                14 Radiology
                               404        Other imaging services-positron emission-tomography (eff 10/94)          14 Radiology
                               409        Other imaging services-other                                             14 Radiology
                               410        Respiratory services-general classification                               9 Inhalation Therapy
                               412        Respiratory services-inhalation services                                  9 Inhalation Therapy
                               413        Respiratory services-hyperbaric oxygen therapy                            9 Inhalation Therapy
                               419        Respiratory services-other                                                9 Inhalation Therapy
                               420        Physical therapy-general classification                                   8 Therapy Services
                               421        Physical therapy-visit charge                                             8 Therapy Services
                               422        Physical therapy-hourly charge                                            8 Therapy Services
                               423        Physical therapy-group rate                                               8 Therapy Services
                               424        Physical therapy-evaluation or re-evaluation                              8 Therapy Services
                               429        Physical therapy-other                                                    8 Therapy Services
                               430        Occupational therapy-general classification                               8 Therapy Services
                               431        Occupational therapy-visit charge                                         8 Therapy Services
                               432        Occupational therapy-hourly charge                                        8 Therapy Services
                               433        Occupational therapy-group rate                                           8 Therapy Services
                               434        Occupational therapy-evaluation or re-evaluation                          8 Therapy Services
                               439        Occupational therapy-other (may include-restorative therapy)              8 Therapy Services
                               440        Speech language pathology-general classification                          8 Therapy Services
                               441        Speech language pathology-visit charge                                    8 Therapy Services
                               442        Speech language pathology-hourly charge                                   8 Therapy Services
                               443        Speech language pathology-group rate                                      8 Therapy Services
                               444        Speech language pathology-evaluation or-re-evaluation                     8 Therapy Services
                               449        Speech language pathology-other                                           8 Therapy Services
                               450        Emergency room-general classification                                    18 ER
                               451        Emergency room-emtala emergency medical screening-services (eff 10/96) ER18
                               452        Emergency room-ER beyond emtala screening-(eff 10/96)                    18 ER
                               456        Emergency room-urgent care (eff 10/96)                                   17 Clinic
                               459        Emergency room-other                                                     18 ER
                               460        Pulmonary function-general classification                                12 Cardiology
                               469        Pulmonary function-other                                                 12 Cardiology
                               470        Audiology-general classification                                          8 Therapy Services
                               471        Audiology-diagnostic                                                      8 Therapy Services
                               472        Audiology-treatment                                                       8 Therapy Services
                               479        Audiology-other                                                           8 Therapy Services
                               480        Cardiology-general classification                                        12 Cardiology
                               481        Cardiology-cardiac cath lab                                              10 Operating Room
                               482        Cardiology-stress test                                                   12 Cardiology
                               483        Cardiology-Echocardiology                                                12 Cardiology
                               489        Cardiology-other                                                         12 Cardiology
                               490        Ambulatory surgical care-general classification                          10 Operating Room
                               499        Ambulatory surgical care-other                                           10 Operating Room
                               500        Outpatient services-general classification-(deleted 9/93)                17 Clinic
                               509        Outpatient services-other (deleted 9/93)                                 17 Clinic
                               510        Clinic-general classification                                            17 Clinic
                               511        Clinic-chronic pain center                                               17 Clinic
                               512        Clinic-dental center                                                     17 Clinic
                               513        Clinic-psychiatric                                                       17 Clinic
                               514        Clinic-OB-GYN                                                            17 Clinic
                               515        Clinic-pediatric                                                         17 Clinic

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[Path]459c59f9-e44b-4ee9-b250-147812fc14dc.xls\ [RevCodes]                      Milliman                                                      Page 3 of 7
                                                                   Revenue Code Reference Table



                             RevCode                        Major Category Description                           Standard Crosswalk Department
                               516        Clinic-urgent care clinic (eff 10/96)                                       17 Clinic
                               517        Clinic-family practice clinic (eff 10/96)                                   17 Clinic
                               519        Clinic-other                                                                17 Clinic
                               520        Free-standing clinic-general classification                                 17 Clinic
                               521        Free-standing clinic-rural health clinic                                    17 Clinic
                               522        Free-standing clinic-rural health home                                      17 Clinic
                               523        Free-standing clinic-family practice                                        17 Clinic
                               526        Free-standing clinic-urgent care (eff 10/96)                                17 Clinic
                               529        Free-standing clinic-other                                                  17 Clinic
                               530        Osteopathic services-general classification                                  8 Therapy Services
                               531        Osteopathic services-osteopathic therapy                                     8 Therapy Services
                               539        Osteopathic services-other                                                   8 Therapy Services
                               540        Ambulance-general classification                                            20 Other Services
                               541        Ambulance-supplies                                                          20 Other Services
                               542        Ambulance-medical transport                                                 20 Other Services
                               543        Ambulance-heart mobile                                                      20 Other Services
                               544        Ambulance-oxygen                                                            20 Other Services
                               545        Ambulance-air ambulance                                                     20 Other Services
                               546        Ambulance-neo-natal ambulance                                               20 Other Services
                               547        Ambulance-pharmacy                                                          20 Other Services
                               548        Ambulance-telephone transmission EKG                                        20 Other Services
                               549        Ambulance-other                                                             20 Other Services
                               550        Skilled nursing-general classification                                      20 Other Services
                               551        Skilled nursing-visit charge                                                20 Other Services
                               552        Skilled nursing-hourly charge                                               20 Other Services
                               559        Skilled nursing-other                                                       20 Other Services
                               560        Medical social services-general classification                              20 Other Services
                               561        Medical social services-visit charge                                        20 Other Services
                               562        Medical social services-hourly charges                                      20 Other Services
                               569        Medical social services-other                                               20 Other Services
                               570        Home health aid (home health)-general-classification                        20 Other Services
                               571        Home health aid (home health)-visit charge                                  20 Other Services
                               572        Home health aid (home health)-hourly charge                                 20 Other Services
                               579        Home health aid (home health)-other                                         20 Other Services
                               580                                                                                    20
                                          Other visits (home health)-general-classification (under HHPPS, not allowedOther Services
                               581                                                                                    20 Other Services
                                          Other visits (home health)-visit charge-(under HHPPS, not allowed as covered charges)
                               582                                                                                    20 Other Services
                                          Other visits (home health)-hourly charge-(under HHPPS, not allowed as covered charges)
                               589                                                                                    20 Other
                                          Other visits (home health)-other-(under HHPPS, not allowed as covered charges) Services
                               590                                                                                    allowed
                                          Units of service (home health)-general-classification (under HHPPS, not 20 Other Services
                               599        Units of service (home health)-other                                        20 Other Services
                               600        Oxygen-general classification                                               20 Other Services
                               601        Oxygen-stat or port equip/supply or count                                   20 Other Services
                               602        Oxygen-stat/equip/under 1 LPM                                               20 Other Services
                               603        Oxygen-stat/equip/over 4 LPM                                                20 Other Services
                               604        Oxygen-stat/equip/portable add-on                                           20 Other Services
                               610        Magnetic resonance technology (MRT)-general-classification                  14 Radiology
                               611        MRT/MRI-brain (including brainstem)                                         14 Radiology
                               612        MRT/MRI-spinal cord (including spine)                                       14 Radiology
                               614        MRT/MRI-other                                                               14 Radiology
                               615        MRT/MRA-Head and Neck                                                       14 Radiology
                               616        MRT/MRA-Lower Extremities                                                   14 Radiology
                               618        MRT/MRA-other                                                               14 Radiology
                               619        MRT/Other MRI                                                               14 Radiology
                               621                                                                                     7 - extension Equipment
                                          Medical/surgical supplies-incident to radiology--subject to the payment limitSupplies andof 027X
                               622                                                                                     7 payment limit -
                                          Medical/surgical supplies-incident to other-diagnostic service-subject to the Supplies and Equipment
                               623                                                                                     7
                                          Medical/surgical supplies-surgical dressings-(eff 1/95) - extension of 027X Supplies and Equipment
                               624                                                                                      with FDA and Equipment
                                          Medical/surgical supplies-medical investigational-devices and procedures 7 Supplies approved IDE's
                               630        Drugs requiring specific identification-general-classification               6 Drugs
                               631        Drugs requiring specific identification-single drug-source (eff 9/93)        6 Drugs
                               632        Drugs requiring specific identification-multiple drug-source (eff 9/93)      6 Drugs
                               633        Drugs requiring specific identification-restrictive-prescription (eff 9/93) 6 Drugs
                               634        Drugs requiring specific identification-EPO under-10,000 units               6 Drugs
                               635        Drugs requiring specific identification-EPO 10,000-units or more             6 Drugs
                               636        Drugs requiring specific identification-detailed-coding (eff 3/92)           6 Drugs
                               637                                                                                     6 Drugs
                                          Self-administered drugs administered in an-emergency situation - not requiring detailed
                               640        Home IV therapy-general classification-(eff 10/94)                          20 Other Services
                               641        Home IV therapy-nonroutine nursing-(eff 10/94)                              20 Other Services
                               642        Home IV therapy-IV site care, central line-(eff 10/94)                      20 Other Services
                               643        Home IV therapy-IV start/change peripheral line-(eff 10/94)                 20 Other Services
                               644        Home IV therapy-nonroutine nursing, peripheral line-(eff 10/94)             20 Other Services
                               645        Home IV therapy-train patient/caregiver, central-line (eff 10/94)           20 Other Services
                               646        Home IV therapy-train disabled patient, central-line (eff 10/94)            20 Other Services

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[Path]459c59f9-e44b-4ee9-b250-147812fc14dc.xls\ [RevCodes]                       Milliman                                                        Page 4 of 7
                                                                   Revenue Code Reference Table



                             RevCode                        Major Category Description                         Standard Crosswalk Department
                               647        Home IV therapy-train patient/caregiver, peripheral-line (eff 10/94)       20 Other Services
                               648        Home IV therapy-train disabled patient, peripheral-line (eff 10/94)        20 Other Services
                               649        Home IV therapy-other IV therapy services-(eff 10/94)                      20 Other Services
                               650        Hospice services-general classification                                    20 Other Services
                               651        Hospice services-routine home care                                         20 Other Services
                               652        Hospice services-continuous home care-1/2                                  20 Other Services
                               655        Hospice services-inpatient care                                            20 Other Services
                               656        Hospice services-general inpatient care-(non-respite)                      20 Other Services
                               657        Hospice services-physician services                                        20 Other Services
                               659        Hospice services-other                                                     20 Other Services
                               660        Respite care (HHA)-general classification-(eff 9/93)                       20 Other Services
                               661        Respite care (HHA)-hourly charge/skilled nursing-(eff 9/93)                20 Other Services
                               662                                                                                   20
                                          Respite care (HHA)-hourly charge/home health aide/-homemaker (eff 9/93) Other Services
                               670        OP special residence charges - general-classification                      20 Other Services
                               671        OP special residence charges - hospital based                              20 Other Services
                               672        OP special residence charges - contracted                                  20 Other Services
                               679        OP special residence charges - other special-residence charges             20 Other Services
                               700        Cast room-general classification                                           20 Other Services
                               709        Cast room-other                                                            20 Other Services
                               710        Recovery room-general classification                                       10 Operating Room
                               719        Recovery room-other                                                        10 Operating Room
                               720        Labor room/delivery-general classification                                  3 Labor and Delivery
                               721        Labor room/delivery-labor                                                   3 Labor and Delivery
                               722        Labor room/delivery-delivery                                                3 Labor and Delivery
                               723        Labor room/delivery-circumcision                                            3 Labor and Delivery
                               724        Labor room/delivery-birthing center                                         3 Labor and Delivery
                               729        Labor room/delivery-other                                                   3 Labor and Delivery
                               730        EKG/ECG-general classification                                             12 Cardiology
                               731        EKG/ECG-Holter moniter                                                     12 Cardiology
                               732        EKG/ECG-telemetry (include fetal monitering until-9/93)                    12 Cardiology
                               739        EKG/ECG-other                                                              12 Cardiology
                               740        EEG-general classification                                                 12 Cardiology
                               749        EEG (electroencephalogram)-other                                           12 Cardiology
                               750        Gastro-intestinal services-general classification                          20 Other Services
                               759        Gastro-intestinal services-other                                           20 Other Services
                               760        Treatment or observation room-general-classification                       19 Observation
                               761        Treatment or observation room-treatment room-(eff 9/93)                    19 Observation
                               762        Treatment or observation room-observation room-(eff 9/93)                  19 Observation
                               769        Treatment or observation room-other                                        19 Observation
                               770        Preventative care services-general classification-(eff 10/94)              20 Other Services
                               771        Preventative care services-vaccine administration-(eff 10/94)              20 Other Services
                               779        Preventative care services-other (eff 10/94)                               20 Other Services
                               780        Telemedicine - general classification-(eff 10/97)                          20 Other Services
                               789        Telemedicine - telemedicine (eff 10/97)                                    20 Other Services
                               790        Lithotripsy-general classification                                         10 Operating Room
                               799        Lithotripsy-other                                                          10 Operating Room
                               800        Inpatient renal dialysis-general classification                            16 Dialysis
                               801        Inpatient renal dialysis-inpatient hemodialysis                            16 Dialysis
                               802        Inpatient renal dialysis-inpatient peritoneal-(non-CAPD)                   16 Dialysis
                               803        Inpatient renal dialysis-inpatient CAPD                                    16 Dialysis
                               804        Inpatient renal dialysis-inpatient CCPD                                    16 Dialysis
                               809        Inpatient renal dialysis-other inpatient dialysis                          16 Dialysis
                               810        Organ acquisition-general classification                                   21 Organ Acquisition Costs
                               811                                                                                   21 Organ Acquisition Costs
                                          Organ acquisition-living donor (eff 10/94);-prior to 10/94, defined as living donor kidney
                               812                                                                                   21 Organ Acquisition
                                          Organ acquisition-cadaver donor (eff 10/94);-prior to 10/94, defined as cadaver donor kidney Costs
                               813                                                                                   21 Organ Acquisition
                                          Organ acquisition-unknown donor (eff 10/94)-prior to 10/94, defined as unknown donor kidneyCosts
                               814                                                                                   21 Organ Acquisition
                                          Organ acquisition - unsuccessful organ search--donor bank charges (eff 10/94); prior to 10/94, Costs
                               815        Organ acquisition-cadaver donor-heart-(obsolete, eff 10/94)                21 Organ Acquisition Costs
                               816        Organ acquisition-other heart acquisition-(obsolete, eff 10/94)            21 Organ Acquisition Costs
                               817        Organ acquisition-donor-liver-(obsolete, eff 10/94)                        21 Organ Acquisition Costs
                               819                                                                                   21
                                          Organ acquisition-other donor (eff 10/94);-prior to 10/94, defined as other Organ Acquisition Costs
                               820        Hemodialysis OP or home dialysis-general-classification                    16 Dialysis
                               821        Hemodialysis OP or home dialysis-hemodialysis--composite or other rate16 Dialysis
                               822        Hemodialysis OP or home dialysis-home supplies                             16 Dialysis
                               823        Hemodialysis OP or home dialysis-home equipment                            16 Dialysis
                               824        Hemodialysis OP or home dialysis-maintenance/100%                          16 Dialysis
                               825        Hemodialysis OP or home dialysis-support services                          16 Dialysis
                               829        Hemodialysis OP or home dialysis-other                                     16 Dialysis
                               830        Peritoneal dialysis OP or home-general-classification                      16 Dialysis
                               831        Peritoneal dialysis OP or home-peritoneal--composite or other rate         16 Dialysis
                               832        Peritoneal dialysis OP or home-home supplies                               16 Dialysis
                               833        Peritoneal dialysis OP or home-home equipment                              16 Dialysis

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[Path]459c59f9-e44b-4ee9-b250-147812fc14dc.xls\ [RevCodes]                       Milliman                                                         Page 5 of 7
                                                                   Revenue Code Reference Table



                             RevCode                       Major Category Description                         Standard Crosswalk Department
                               834        Peritoneal dialysis OP or home-maintenance/100%                           16 Dialysis
                               835        Peritoneal dialysis OP or home-support services                           16 Dialysis
                               839        Peritoneal dialysis OP or home-other                                      16 Dialysis
                               840        CAPD outpatient-general classification                                    16 Dialysis
                               841        CAPD outpatient-CAPD/composite or other rate                              16 Dialysis
                               842        CAPD outpatient-home supplies                                             16 Dialysis
                               843        CAPD outpatient-home equipment                                            16 Dialysis
                               844        CAPD outpatient-maintenance/100%                                          16 Dialysis
                               845        CAPD outpatient-support services                                          16 Dialysis
                               849        CAPD outpatient-other                                                     16 Dialysis
                               850        CCPD outpatient-general classification                                    16 Dialysis
                               851        CCPD outpatient-CCPD/composite or other rate                              16 Dialysis
                               852        CCPD outpatient-home supplies                                             16 Dialysis
                               853        CCPD outpatient-home equipment                                            16 Dialysis
                               854        CCPD outpatient-maintenance/100%                                          16 Dialysis
                               855        CCPD outpatient-support services                                          16 Dialysis
                               859        CCPD outpatient-other                                                     16 Dialysis
                               880        Miscellaneous dialysis-general classification                             16 Dialysis
                               881        Miscellaneous dialysis-ultrafiltration                                    16 Dialysis
                               882        Miscellaneous dialysis-home dialysis aide visit-(eff 9/93)                16 Dialysis
                               889        Miscellaneous dialysis-other                                              16 Dialysis
                               890                                                                                   assignment (eff 4/94)
                                          Other donor bank-general classification; changed to-reserved for national20 Other Services
                               891                                                                                   4/94)
                                          Other donor bank-bone; changed to-reserved for national assignment (eff20 Other Services
                               892                                                                                  20 Other Services
                                          Other donor bank-organ (other than kidney); changed-to reserved for national assignment (eff 4/94)
                               893                                                                                  20 Other Services
                                          Other donor bank-skin; changed to-reserved for national assignment (eff 4/94)
                               899                                                                                   4/94)
                                          Other donor bank-other; changed to-reserved for national assignment (eff20 Other Services
                               900        Psychiatric/psychological treatments-general-classification               20 Other Services
                               901        Psychiatric/psychological treatments-electroshock-treatment               20 Other Services
                               902        Psychiatric/psychological treatments-milieu-therapy                       20 Other Services
                               903        Psychiatric/psychological treatments-play-therapy                         20 Other Services
                               904        Psychiatric/psychological treatments-activity-therapy (eff 4/94)          20 Other Services
                               909        Psychiatric/psychological treatments-other                                20 Other Services
                               910        Psychiatric/psychological services-general-classification                 20 Other Services
                               911        Psychiatric/psychological services-rehabilitation                         20 Other Services
                               912                                                                                  20 Other Services
                                          Psychiatric/psychological services-day care--redefined 10/97 to less Intensive
                               913                                                                                  2
                                          Psychiatric/psychological services-night care-redefined 10/97 to Intensive 0 Other Services
                               914        Psychiatric/psychological services-individual-therapy                     20 Other Services
                               915        Psychiatric/psychological services-group therapy                          20 Other Services
                               916        Psychiatric/psychological services-family therapy                         20 Other Services
                               917        Psychiatric/psychological services-biofeedback                            20 Other Services
                               918        Psychiatric/psychological services-testing                                20 Other Services
                               919        Psychiatric/psychological services-other                                  20 Other Services
                               920        Other diagnostic services-general classification                          20 Other Services
                               921        Other diagnostic services-peripheral vascular lab                         20 Other Services
                               922        Other diagnostic services-electromyelogram                                20 Other Services
                               923        Other diagnostic services-pap smear                                       20 Other Services
                               924        Other diagnostic services-allergy test                                    20 Other Services
                               925        Other diagnostic services-pregnancy test                                  20 Other Services
                               929        Other diagnostic services-other                                           20 Other Services
                               940        Other therapeutic services-general classification                         20 Other Services
                               941        Other therapeutic services-recreational therapy                           20 Other Services
                               942                                                                                  20
                                          Other therapeutic services-education/training-(include diabetes diet training)Other Services
                               943        Other therapeutic services-cardiac rehabilitation                         20 Other Services
                               944        Other therapeutic services-drug rehabilitation                            20 Other Services
                               945        Other therapeutic services-alcohol-rehabilitation                         20 Other Services
                               946        Other therapeutic services-routine complex-medical equipment              20 Other Services
                               947                                                                                  20
                                          Other therapeutic services-ancillary complex-medical equipment (eff 3/92) Other Services
                               949        Other therapeutic services-other                                          20 Other Services
                               951        Professional Fees-athletic training                                       20 Other Services
                               952        Professional Fees-kinesiotherapy                                          20 Other Services
                               960        Professional fees-general classification                                  20 Other Services
                               961        Professional fees-psychiatric                                             20 Other Services
                               962        Professional fees-ophthalmology                                           20 Other Services
                               963        Professional fees-anesthesiologist (MD)                                   20 Other Services
                               964        Professional fees-anesthetist (CRNA)                                      20 Other Services
                               969        Professional fees-other                                                   20 Other Services
                               971        Professional fees-laboratory                                              20 Other Services
                               972        Professional fees-radiology diagnostic                                    20 Other Services
                               973        Professional fees-radiology therapeutic                                   20 Other Services
                               974        Professional fees-nuclear medicine                                        20 Other Services
                               975        Professional fees-operating room                                          20 Other Services
                               976        Professional fees-respiratory therapy                                     20 Other Services

 [Date] 1:31 PM
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                                                                   Revenue Code Reference Table



                             RevCode                       Major Category Description             Standard Crosswalk Department
                               977        Professional fees-physical therapy                           20 Other Services
                               978        Professional fees-occupational therapy                       20 Other Services
                               979        Professional fees-speech pathology                           20 Other Services
                               981        Professional fees-emergency room                             20 Other Services
                               982        Professional fees-outpatient services                        20 Other Services
                               983        Professional fees-clinic                                     20 Other Services
                               984        Professional fees-medical social services                    20 Other Services
                               985        Professional fees-EKG                                        20 Other Services
                               986        Professional fees-EEG                                        20 Other Services
                               987        Professional fees-hospital visit                             20 Other Services
                               988        Professional fees-consultation                               20 Other Services
                               989        Professional fees-private duty nurse                         20 Other Services
                               990        Patient convenience items-general classification             20 Other Services
                               991        Patient convenience items-cafeteria/guest tray               20 Other Services
                               992        Patient convenience items-private linen service              20 Other Services
                               993        Patient convenience items-telephone/telegraph                20 Other Services
                               994        Patient convenience items-tv/radio                           20 Other Services
                               995        Patient convenience items-nonpatient room rentals            20 Other Services
                               996        Patient convenience items-late discharge charge              20 Other Services
                               997        Patient convenience items-admission kits                     20 Other Services
                               998        Patient convenience items-beauty shop/barber                 20 Other Services
                               999        Patient convenience items-other-                             20 Other Services




 [Date] 1:31 PM
[Path]459c59f9-e44b-4ee9-b250-147812fc14dc.xls\ [RevCodes]                      Milliman                                          Page 7 of 7

								
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