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Questions and Answers
Define packaging as it pertains to OPPS.
Define packaging as it pertains to OPPS.
Occurs when reimbursement for minor ancillary services associated with a significant procedure is combined into a single payment for the procedure.
Define bundling as it pertains to OPPS.
Define bundling as it pertains to OPPS.
Occurs when payment for multiple significant procedures or multiple units of the same procedure related to an outpatient encounter or to an episode-of-care is combined into a single unit of payment.
Which reimbursement method uses SI Q3?
Which reimbursement method uses SI Q3?
Composite APC payment.
Which reimbursement method uses SI K?
Which reimbursement method uses SI K?
Which reimbursement method uses SI J1?
Which reimbursement method uses SI J1?
Which reimbursement method uses SI Q4?
Which reimbursement method uses SI Q4?
In an outpatient ambulatory surgery encounter with codes SI J1, SI T, SI S, which codes are separately payable and which are packaged?
In an outpatient ambulatory surgery encounter with codes SI J1, SI T, SI S, which codes are separately payable and which are packaged?
Describe discontinuing as it applies to payment SI T.
Describe discontinuing as it applies to payment SI T.
What are CCRs?
What are CCRs?
What is PPS?
What is PPS?
What is MedPAC?
What is MedPAC?
Define OPPS.
Define OPPS.
What does ASP stand for?
What does ASP stand for?
What is APC?
What is APC?
What are SIs?
What are SIs?
A high-cost supply that is reimbursed under a different reimbursement methodology than other supplies is known as a __________.
A high-cost supply that is reimbursed under a different reimbursement methodology than other supplies is known as a __________.
What is a PHP?
What is a PHP?
What are CMHCS?
What are CMHCS?
What does MPFS stand for?
What does MPFS stand for?
Define per diem APC payment.
Define per diem APC payment.
What are comprehensive APC payments?
What are comprehensive APC payments?
What is conditional APC payment?
What is conditional APC payment?
What is composite APC payment?
What is composite APC payment?
A payment method calculated by multiplying the charge for the service times the CCR is known as __________.
A payment method calculated by multiplying the charge for the service times the CCR is known as __________.
Under OPPS, outpatient services that are similar both clinically and in use of resources are assigned to separate groups called __________.
Under OPPS, outpatient services that are similar both clinically and in use of resources are assigned to separate groups called __________.
Which of the following statements is true about APCs? a. APCs are based solely on the patient's principal diagnosis. b. ICD-10-CM procedure codes are used to group patients. c. Severity of illness is taken into consideration when grouping APCs. d. APCs are based on the CPT or HCPCS code(s) reported.
Which of the following statements is true about APCs? a. APCs are based solely on the patient's principal diagnosis. b. ICD-10-CM procedure codes are used to group patients. c. Severity of illness is taken into consideration when grouping APCs. d. APCs are based on the CPT or HCPCS code(s) reported.
What does the status indicator T indicate?
What does the status indicator T indicate?
What does the relative weight APC component measure?
What does the relative weight APC component measure?
The national unadjusted payment amount is the product of the conversion factor multiplied by the relative weight, unadjusted for __________.
The national unadjusted payment amount is the product of the conversion factor multiplied by the relative weight, unadjusted for __________.
Which type of service includes an APC per diem methodology that includes payment for all services provided on a single day of service under OPPS? a. Clinic visits b. Partial hospitalization c. Emergency department visits d. Same-day surgery
Which type of service includes an APC per diem methodology that includes payment for all services provided on a single day of service under OPPS? a. Clinic visits b. Partial hospitalization c. Emergency department visits d. Same-day surgery
What is the modifier included in the interrupted services provision under OPPS?
What is the modifier included in the interrupted services provision under OPPS?
Study Notes
Medicare Outpatient Payment System (OPPS) Key Concepts
- Packaging: Combines reimbursement for minor ancillary services linked to a significant procedure into a single payment.
- Bundling: Merges payments for multiple significant procedures, or multiple units of the same procedure in an outpatient visit into one payment.
- Composite APC Payment: Uses SI Q3 as a reimbursement method.
- APC Payment: Identified by SI K, pertains to specific outpatient services.
- Comprehensive APC Payment (C-APC): Links higher-level procedures with SI J1 for payment purposes.
- Conditional APC Payment: Refers to SI Q4; covers items/services not separately paid when related to a primary service.
Reimbursement Methods and Codes
- Claims for outpatient surgery can have multiple codes, where SI J1 is separately payable, while SIs T and S are packaged.
- Discontinuing Services: Policy where the highest-weighted procedure receives full reimbursement, and others with SI T are paid at 50%.
- Cost-to-Charge Ratios (CCRs): Measure of operating costs versus revenues, essential for calculating reasonable cost payments.
- Prospective Payment System (PPS): Medicare's predetermined fixed payment method for inpatient services.
Payment and Classification Systems
- Ambulatory Payment Classification (APC): Determines outpatient service reimbursement rates based on specific groupings of clinically comparable procedures.
- Status Indicators (SIs): Codes that indicate how services are reimbursed under OPPS, with specific meanings, like G for pass-through drugs and T for surgical procedures with multiple procedure reduction.
- Comprehensive APCs, indicated by SIs J1 and J2, aim to streamline payment processes for outpatient services.
- Specific methodologies like Per diem APC use daily fixed rates for hospitalizations.
Provisions and Adjustments under OPPS
- OPPS Provisions: Include high-cost items, interrupted services, and adjustments for rural hospitals or dedicated cancer facilities.
- High-Cost Outlier Adjustment: Compensation for exceptionally expensive services relative to typical costs.
- Cancer Hospital Adjustment: Provides extra support for facilities dedicated to cancer treatment due to their higher operational costs.
Unique Payment Concepts
- Packages: Refers to payments that combine specific service types, indicated by SI N, to facilitate cost-effective care.
- Non-Reimbursed Services: Identified by various SIs that denote procedures not deemed necessary or appropriate for outpatient settings.
- OCE (Outpatient Code Editor): Software used to implement packaging logic in OPPS, ensuring systematic billing and coding accuracy.
General Guidelines and Additional Terminology
- Conversion Factor (CF): A vital multiplier for determining payment rates across services in the Medicare system.
- Core Based Statistical Area (CBSA): Influences the cost index applied to facilities based on location.
- Partial Hospitalization Program (PHP): Offers intensive outpatient psychiatric services as an alternative to inpatient care.
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Description
Test your knowledge of the Medicare Hospital Outpatient Payment System through these flashcards focusing on key concepts like packaging and bundling. Perfect for students and professionals looking to deepen their understanding of outpatient payment methods.
