Ch.5 Outpatient Prospective Systems Flashcards
Out patient Prospective Payment Systems (OPPS)
implemented 2000
based on fixed rates, predetermined, paid under medicare part B
Outpatient prospective system was decided based on
success on inpatient , so wanted to implement PPS on continuum level of care
OPPS services include
hospital based clinics
emergency dept visits
observations
ambulatory surgery depts
goal of OPPS
shift financial risk to hospital rather medicare, creat incentive for cost control
CMS maintains ?
inpatient-only list
which is services medicare only pay when performed in the inpatient setting
Ambulatory Payment Classifications (APC)
used to reimburse outpatient services
all outpatient services assigned to APC group
payment is prospective, fixed, annually updated
two times rule
median cost of most expensive item/service within a group cannot be 2x > median cost of least expensive within same group
procedures are identified by
Healthcare common procedure codes system
HCPCS
HCPCS level I
current procedural terminology (CPT) codes all procedures and services done by physicians, nonphys practitioners, hospital labs, outpatient facilities
consist of 5 numbers
maintain by AMA
HCPCS level II
code set used by provider and medical equipment suppliers
maintained by CMS
consist of 5 characters made up of a letter, 4 number
APC payments are determined by
HCPCS codes
CPT code identify
procedure
HCPCS II code is added when
required to report products that may have been prescribed, injected, or otherwise delivered to the pt during the service
payment rate and copayment calculated for APC applies to
each service within APC group
Packaging is when
minor ancillary services associated with procedure is combined for single payment
only used in OPPS
bundling occurs
when predetermined set services performed together during encounter result in reimbursement for all services combined into one payment
assigned by CMS to HCPCS codes to id whether payment is made separately or as packaged
status indicators
when services with status indicators are performed
associate ancillary/supportive items are packaged into payment
each APC is weighted and has a
prospective payment amount associated
if patient is assigned multiple APCs the payments are
totaled to provide reimbursement to hospital for encounter
weights are based on
average resources used to treat patients in a particular APC -avg 1.000
applied to the relative weight by CMS
a conversion factor
adjusts payments to account for geographic variations in labor cost
wage index
provides additional reimbursement to hospitals that use innovative biologicals, drugs, technology
add ons
Ambulatory Surgical Center (ASC)
furnish outpatient services to pt who do not require hospitalization - less 24 hours following admission
payment for ASC
under medicare part B
ASC payment system used
Ambulatory surgical center payment rates are
predetermined amounts
ASC reimbursed 80% after adjustment for regional variation
outpatient code editors (OCE)
software programs that medicare administrative contractors (MACs) use to audit coding data
OCE basic functions
- edit data on claim for accuracy
- specify action the MAC should take when an edit occur
- assign APC to claim for hospital outpatient service
- determine payment related conditions that require a direct reference to HCPCS codes on modifier
applied to claims on individual diagnosies and procedure sets
edits
goal of edits is to
weed out incomplete or incorrect claims, detect fraud and abuse, encourage correct application of coding guideline
actions when OCE edit occur
-claim may be rejected
-claim may be denied
-claim may be place on suspension
Skilled Nursing facility (SNF)
provide short term skilled nursing care and rehab service to medicare beneficiaries after acute inpatient hospitalization
medicare beneficiaries are eligible for SNF services when ?
immediately after acute inpatient hospitalization of at least 3 days
may receive up to 100 days covered per benefit period
7 major RUG categories
rehabilitation
extensive services
special care
clinically complex
impaired cognition
behavior only
decreased physical function
each RUG have their own
associated nursing and therapy weights applied to the base rate
the payment to the SNF for resident care is a
combination of the base rate and the resident’s RUG score
home health services covered under
medicare A & b
patient driven groupings model (PDGM)
focus on clinical characteristics to better align medicare payment with patient care needs
under PDGM, 3 domain components of the home health resource group remain same which is
clinical
functional
service
