Part 2 Chapter 7 OPPS

Chapter 7 Part 2 - OPPS

Payment Status Indicators & Provisions of OPPS

Multiple Select

What methods does CMS use to reimburse for hospital outpatient services? (Select all that apply)

• per diem

• fee schedule

• prospective payment

• reasonable cost/cost-based

• % of billed charges

Match

Match the following

• Bundling

• Packaging

• A

payments for multiple significant procedures are combined into one payment

Payments for minor ancillary services are bundled with the payment for a significant procedure

A

• payments for multiple significant procedures are combined into one payment

• Payments for minor ancillary services are bundled with the payment for a significant procedure

• A

Match

Match the following

• Bundling

• Packaging

• A

MRI of neck

MRI of chest

MRI of the low back

combined into one payment

IV start

blood draw

surgical tray

appendectomy

combined into one payment

A

• MRI of neck

  MRI of chest

  MRI of the low back

  combined into one payment

• IV start

  blood draw

  surgical tray

  appendectomy

  combined into one payment

• A

​Payment Status Reimbursement

To understand how an encounter is reimbursed under OPPS, the SI's must be accurately assigned. Each category cannot be assessed alone, instead, all of the SIs must be used in combination to determine the reimbursement.

• The 9 currently used SIs are:

• APC payment

• Per Diem APC payment

• Comprehensive APC payment

• Conditional APC payment

• Composite APC payment

• Packaged payment

• Fee Schedule Payment

• Reasonable cost payment

• Services not reimbursed under OPPS

APC Payment

SI - G K R S T U V

These services are reimbursed by the prospective payment methodology.

Read what services these are on page 110.

When services with one of the above SIs are performed, their ancillary services are packaged into the payment (Read example 7.3)

Open Ended

What is SI U representative of?

What is SI G representative of?

Per Diem APC Payment

SI - P

(on the test) the PHP (Partial Hospitalization Program) is an intensive outpatient program for psychiatric patients as an alternative to inpatient psychiatric admission, for patients with acute mental illness.

The unit of service for partial hospitalization is one day.

Fill in the Blanks

What is the unit of service for PHP program?

Comprehensive APC Payment

SI- J1 J2

These are all inclusive APC categories. A primary procedure is identified, and then most other procedures, services, and supplies are packaged into the C-APC payment amount.

The highest ranking APC per CMS is the primary procedure.

See Figure 7.2 for an example. (Page 111)

Conditional APC Payment

SI- Q1 Q2 Q4

(on the test) These services are conditional packaged ONLY when certain criteria are met.

Q1- STV package: When an ancillary service is performed without an SI of S, T, or V, then payment is provided for the ancillary service.

Q2 - T Package: If ancillary service is performed with an SI T, then the ancillary service is paid. See example 7.4 page 112

Q4 - Lab package - If a lab test is reported on a claim without another service with SI J1, J2, S, T, V, Q1, Q2, or Q3, then the lab test is paid.

Composite APC Payment

SI- Q3

Formed by grouping services that are always performed together into a single payment.

There are currently 8 composite APCs, see table 7.2 pg 112

Read example 7.5

Packaged Payment

SI- N

These items are always packaged.

These services are covered under OPPS, they just do not receive additional payment.

See table 7.4

Fee Schedule

SI- A

Services such as ambulance, physical therapy, and mammography.

Fee schedule amounts are exempt from many of the OPPS payment adjustments and provisions because adjustments (such as geographic adjustments) have already been made.

Reasonable Cost Payment

SI- F H L

A small subset of services fall under this category.

They are paid based on multiplying the charge times the CCR developed from cost report statistics.

Not Reimbursed under OPPS

​SI- B C D E1 E2 M Y

(on the test) SI C is used for inpatient only procedures. CPT codes were originally designed to report all physician services in all settings, but OPPS only covers outpatient procedures so claims data determines which CPT codes are IPO (inpatient only)procedures and creates a list.

In an Inpatient setting, payment is made via IPPS

​ON THE TEST!!!

Read the following provisions in your textbook:

• Interrupted Services

• Rural Hospital Adjustments

• Pass-through payment policy