Ch. 7-Medicare Hospital Outpatient Payment System

Question 1

Ambulatory payment classification (APC)

Answer 1

Resource-based system used in the Medicare Hospital Outpatient Prospective Payment System (OPPS)
Combines procedures and services that are clinically comparable, with respect to resource use, into groups which are used to determine reimbursement levels.

Question 2

Bundling

Answer 2

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

Question 3

Conversion factor (CF)

Answer 3

National dollar multiplier that sets allowance for the relative values; a constant

Question 4

National unadjusted payment

Answer 4

Product of the conversion factor multiplied by the relative weight, unadjusted for geographic differences

Question 5

Outpatient Code Editor (OCE)

Answer 5

Software program designed to process data for OPPS pricing, including executing packaging and bundling logic. Additionally, the OCE edits the claim based on coding and billing requirements

Question 6

Packaging

Answer 6

Occurs when reimbursement for minor ancillary services associated with a significant procedure is combined into a single payment for the procedure

Question 7

Partial hospitalization program (PHP)

Answer 7

Program of intensive psychotherapy that is provided in a day outpatient setting and is designed to keep patients with severe mental conditions from being hospitalized in an inpatient unit

Question 8

Pass-through

Answer 8

Exception to the Medicare outpatient prospective payment methodology for high-cost supplies. Eligible supplies are not packaged under OPPS and are often reimbursed at or near cost

Question 9

Payment status indicator (SI)

Answer 9

Code that establishes how a service, procedure, or item is paid in OPPS
EX: fee schedule, APC, reasonable cost, not paid, etc.

Question 10

Sole-community hospital (SCH)