Overview of How Pulse Medical Data is Structured
Providers and NPIs
All medical providers in the United States have a National Provider Identifier (NPI). There are NPIs for organizations and for individuals. For example, “Regional Women’s Health Group LLC” in Phoenixville, Pennsylvania has an NPI of 1750880118.
Dr. Alyssa Kurtz is a provider that works within this organization, and she has her own NPI (1982265302).
Billing Codes and Billing Code Modifiers
Payers negotiate rates that they agree to pay each provider for their services based on billing codes. For example, 77067 is a billing code used for diagnostic mammography.
Sometimes these billing codes also have two-digit billing code modifiers that are used to provide additional information about the procedure / service / supply. For example, 77067 has a “TC” modifier to indicate the technical component. This involves the use of equipment, supplies, or non-physician staff time. 77067 also has another “26” modifier to represent the professional component of the service, which includes the physician’s time to analyze and interpret the results.
If there’s no billing code modifier listed, the rate is referred to the “global fee,” which is used when the technical and professional services are provided by the same entity or within the same facility and don’t require splitting out the charges.
Tax Identification Numbers
Every negotiated rate that is published for an NPI is also attached to a Tax Identification Number (TIN) that belongs to a business or another NPI.
For our example above, the Tax ID Number (TIN) for the Regional Women’s Health Group, LLC business entity that is registered with the Internal Revenue Service is 22-3693606. This data is technically public, but it can sometimes be difficult to match a Tax ID Number to its associated business entity.
If the Tax ID Number belongs to a person (for example, if it is the Social Security Number of an individual provider), the Tax ID Number is mapped to the provider’s NPI in the payer data instead of their Social Security Number.
Pulse Medical Data Format
Pulse Medical is an online tool that allows you to find and download the negotiated rates that have been published by insurance companies for every Tax Identification Number + National Provider Identifier + billing code combination. You can access it from https://my.pulse.app/.
Following through with our previous example, we can search for rates published by UnitedHealthcare of Pennsylvania for billing code 77067 for Regional Women’s Health Group, LLC and Dr.Kurtz.
After downloading the data, we can see that both NPIs have negotiated rates for billing code 77067 associated with the 22-3693606 TIN.
Dr. Kurtz also has a separate negotiated rate for 77067 with another business (TIN 23-3057914).
You will notice that Regional Women’s Health Group, LLC only has a published rate for the TC billing code modifier and Dr. Kurtz only has a global rate. In Pulse output data, global rates are indicated with an “NA” or “[ ]” value.
In the example above, the data is only displayed for “Office” place of service. Payers will also publish rates for different places of service (like hospitals, home care, ambulatory surgery centers, and others).
How to Identify Providers within a Medical Practice
If you’re exploring a new practice and you want to identify the list of NPIs that have rates for the codes you care about, you should start on the “Browse Providers” page (https://my.pulse.app/medical-providers).
This section of Pulse Medical allows you to search for providers and Tax Identification Numbers without worrying about which specific payers have published data for them.
You can enter filter criteria based on a provider’s taxonomy (the combination of their grouping, classification, and specialty). For example, you can enter “Obstetrics & Gynecology” in the Classification field to filter for just that type of provider.
You can narrow your search further by filtering based on “Region” (state) and “Provider Type” (organization or individual).
You can zoom in on the map to filter your results based on geography:
You can also click the target icon next to any address on your list of providers in the “Provider Details” pane on the right-hand side of the screen to search within a radius of your chosen address.
Click the + icon next to any piece of information in the “Provider Details” pane to add that data to your filter. For example, click the + icon next to any NPI to add it to the NPI field in your active filter and re-execute the search.
Click the Download button to retrieve a Microsoft Excel friendly CSV file with all of the details for your filtered NPI results. You can choose to instantly download the CSV for up to 10,000 records, or save the complete CSV of results to your My Downloads section for future use.
Click on the “Show Associated Businesses” link next to any provider to show the TINs / NPIs for which this NPI has associated rates with one or more payers.
Click on the “Show Payers with Published Rates” link to retrieve the list of payers in the Pulse Medical system that have published rates for this NPI.
Click the copy icon next to the count of NPIs at the top of the “Provider Details” pane to copy the comma separated list of the first 100 NPIs in your search results.
You can use this to paste the values into the NPI field on the “Browse Rates” page or stash them in a text editor for later use.
How to Access Published Rates for a Known Group of Providers
Once you have your list of provider NPIs and/or parent organization TINs, you can navigate over to the Browse Rates page (https://my.pulse.app/medical) to find rates published by the payers.
The filters on the Browse Rates page are very similar to what you have already used on the Browse Providers page, but the data will also be filtered based on the payer(s) and billing code(s) you have selected.
Even if a provider exists in the system, you will only be able to retrieve them from the Browse Rates page if you enter a payer that has published data for them in the filter criteria.
Optionally filter by Billing Code Modifiers or Place of Service.
Click the Download button and choose to either instantly download up to 10,000 records or save all of your filtered results to your My Downloads section.
Note: the Preview Results button is only used to see what data exists for payers that you are not already licensed for (but the values in the rates columns will be blank).
