GP1 - Grouping/Reimbursement - Visit Segment

These fields are used in grouping and reimbursement for CMS APCs. Please refer to the "Outpatient Prospective Payment System Final Rule" ("OPPS Final Rule") issued by CMS.

The GP1 segment is specific to the US and may not be implemented in non-US systems.

HL7 Attribute Table - GP1 - Grouping/Reimbursement - Visit Segment

Seq#	Data Element Name	DataType	Usage	Vocabulary	Cardinality	Item #	Length	C.LEN	Flags
GP1
1	Type of Bill Code	CWE	R	0455 Type of Bill Code	[1..1]	01599
2	Revenue Code	CWE	O	0456(S) Revenue code(Suggested)	[0..*]	01600
3	Overall Claim Disposition Code	CWE	O	0457 Overall Claim Disposition Code	[0..1]	01601
4	OCE Edits per Visit Code	CWE	O	0458 OCE Edit Code	[0..*]	01602
5	Outlier Cost	CP	O		[0..1]	00387

GP1-1: Type of Bill Code (CWE) 01599

Definition: This field is the same as UB92 Form Locator 4 "Type of Bill". Refer to User-defined Table 0455 - Type of Bill Code in Chapter 2C, Code Tables, for suggested values. Refer to a UB specification for additional information. This field is defined by CMS or other regulatory agencies. It is a code indicating the specific type of bill with digit 1 showing type of facility, digit 2 showing bill classification, and digit 3 showing frequency.

GP1-2: Revenue Code (CWE) 01600

Definition: This field is the same as UB92 Form Locator 42 "Revenue Code". Refer to User-defined Table 0456 - Revenue Code in Chapter 2C, Code Tables, for suggested values. This field identifies revenue codes that are not linked to a HCPCS/CPT code. It is used for claiming for non-medical services such as telephone, TV or cafeteria charges, etc. There can be many per visit or claim. This field is defined by CMS or other regulatory agencies.

There can also be a revenue code linked to a HCPCS/CPT code. These are found in GP2-1 - Revenue Code. Refer to UB92 specifications.

GP1-3: Overall Claim Disposition Code (CWE) 01601

Definition: This field identifies the final status of the claim. The codes listed as examples are not an exhaustive or current list, refer to OPPS Final Rule. Refer to User-defined Table 0457 - Overall Claim Disposition Code in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

GP1-4: OCE Edits per Visit Code (CWE) 01602

Definition: This field contains the edits that result from processing the HCPCS/CPT procedures for a record after evaluating all the codes, revenue codes, and modifiers. The codes listed as examples are not an exhaustive or current list, refer to OPPS Final Rule. OCE (Outpatient Code Editor) edits also exist at the pre-procedure level. Refer to User-defined Table 0458 - OCE Edit Code in Chapter 2C, Code Tables, for suggested values. This field is defined by CMS or other regulatory agencies.

GP1-5: Outlier Cost (CP) 00387

Definition: This field contains the amount that exceeds the outlier limitation as defined by APC regulations. This field is analogous to DRG-7 - Outlier Cost; however, the definition in this field note supersedes the DRG-7 definition.