How does the department calculate payments for covered outpatient services through the outpatient prospective payment system (OPPS)?
(1) Billed services that are reimbursed by the OPPS are grouped into one or more APCs using the outpatient code editor software. (2) Additional payment may be made for services classified by CMS as transitional pass-through. (3) Incidental services are grouped within an APC and are not paid separately. (4) The OPPS APC payment method uses an APC relative weight for each classification group (APC) and the current hospital-specific blended rate to determine the APC payment for an individual service. (5) For each additional APC listed on a single claim for services, the payment is calculated with the same formula and then discounted. L&I follows all discounting policies used by CMS for the Medicare Prospective Payment System for Hospital Outpatient Department Services. (6) APC payment for each APC = (APC relative weight x hospital-specific blended rate)* discount factor (if applicable) x units (if applicable). (7) The total payment on an APC claim is determined mathematically as follows:
Related Questions
- With the implementation of the Outpatient Perspective Payment System (OPPS), can a hospital-based Rural Health Clinic (RHC) bill for RHC services and non- RHC services on the same claim?
- With the implementation of the Outpatient Perspective Payment System (OPPS), can a hospital-based Rural Health Clinic (RHC) bill for RHC services and non-RHC services on the same claim?
- How are observation stays impacted by the TRICARE outpatient prospective payment system (OPPS)?
