Exam 2 Flashcards
OPPS
Outpatient Prospective Payment System
Implemented Aug. 1, 2000 to replace fee-for service Medicare reimbursement with a fixed, prospectively determined payment system for products and services provided by outpatient treatment facilities
Due to escalating outpatient healthcare costs, Congress asked via Omnibus Budget Reconciliation Act (OBRA) legislation of 1986 & 1990 for the secretary of the HHS to develop a proposal for an outpatient PPS system
The Balanced Budget Act of 1997 provided for implementation of a PPS for most hospitals outpatient services effective 1/1/99
Implementation was delayed until 8/1/2000 due to Y2K system concerns
APC
Ambulatory Payment Classification
Developed by CMS for hospital outpatient (facility) reimbursement
Pays for:
◦Designated outpatient services
◦Certain Medicare Part B services furnished to hospital inpatients who do not have Part A coverage◦Partial hospitalization services
◦714 APCs for CY 2018
Hospital Exceptions
•Hospitals that only provide Part B services to inpatients
•Critical Access Hospitals
•Indian Health Service and Tribal Hospitals
•Hospitals in
◦American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Virgin Islands and Maryland hospitals paid under waiver provisions
APC Group Example
APCs classify procedures/services similar clinically& in resource costs and assigns them to
APC groups for payment:
◦Example APC group 0170 Dialysis contains:◦G0257 Unscheduled or emergency dialysis in a hospital◦90935 Hemodialysis, one eval
◦Both of these codes pay the same!
Two time rule
Items and services within an APC can not be grouped together if the highest cost item is more than two times greater than the lowest cost item within the same group
How to Calculate an APC Payment?
Conversion Factor x APC Relative weight
High Cost Outlier Payment
Outlier payments
◦threshold hit when service exceeds 1.75 X APC pmt amount—(if cost is at least 1.75 more than APC amt) and exceeds the APC payment rate by $2,900 facility will be paid 50% of excess
Affordable Care Act
Preventative Services (effective 2011)
◦Patient costs sharing requirement (deductible and co-insurance) are waived for mostpreventative services
◦There is a US Preventative Service Task Force that prepares a list of those services considered preventative
APCs are based on HCPCS codes
Each HCPCS code has a payment status indicator (SI) attached
The payment SI determines if and how the service is paid (examples):
◦C-Inpt procedure—not paid under OPPS
◦S-Significant procedure not discounted when multiple
◦T- Significant procedure discounted when multiple
Multiple APCs can be paid in one visit
Some services are still paid under a fee schedule
Key Features of APC System
Packaging services-services integral to the delivery of a service and contribute to the cost of the service.
Composite APCs
•In CY 2008, CMS developed composite APCs to provide a single payment for services that are generally performed together in a single encounter. There were no new composite APCs created for CY 2018.
Coding Systems for OPPS
- Opportunities for upcoding are minimal
- APC groups based on HCPCS codes
- Level I-CPT
- Level II-National codes
- Medicare mandates use of Level II, other payers may require Level I
Information Systems
Encoder ◦CPT/HCPCS code selection ◦Modifier assignments ◦CCI edits APC grouper ◦Status indicator ◦APC designations ◦Weights ◦APC payment (incl. packaging & discounting)
OCE & NCCI are what?
What is the goal?
The OCE and NCCI are two editing systems used to process claims using CPT and HCPCS Level II codes and modifiers
Goal: to identify coding patterns resulting in overpayment to providers
OCE
What are the 3 major functions?
Outpatient Code Editor
Developed in 1996
is a software package supplied by CMS. This version of the OCE processes claims consisting of multiple days of service.
The OCE performs three major functions:
Edit the data to identify errors and return a series of edit flags.
Assign an Ambulatory Payment Classification (APC) number for each service covered under OPPS, and return information to be used as input to a PRICER program.
Assign an Ambulatory Surgical Center (ASC) payment group for services on claims from certain Non-OPPS hospitals.
NCCI means?
When was it added? and added to who?
What is the goal?
National corrective coding initiative
Added to the OCE in 2000
NCCI edits are used by those who process physician payments under the Medicare Physician Fee Schedule
edits are developed based on coding conventions defined in the AMA’s CPT book, current standards of medical and surgical coding practice, input from specialty societies, and based on analysis of current coding practice.
NCCI does not review across service dates!
NCCI goal is to promote national correct coding and to control improper coding that could lead to inappropriate payments.
NCCI Prohibits unbundling of outpatient procedures via three types of edits:
Comprehensive/Component edits aka Column1/Column 2
Mutually Exclusive Edits aka Column1/Column2
Medically Unlikely Edits
Comprehensive/Component edits aka Column1/Column 2
Code pairs that should not be billed together because one service inherently includes another
Codes are broken into two procedure tables. In each table there are two columns of codes that represent services that should not be coded together.
If an encounter has codes from both columns, this creates an edit pair. If both codes from the edit pair are billed for the same beneficiary, same date of service, by the same performing provider, the Column 1 is eligible for payment and the Column 2 code is subject to denial as the service is considered integral.
Mutually exclusive edits
Code pairs that clinically are unlikely to be performed on the same patient on the same day
Codes are broken into two procedure tables. In each table there are two columns of codes that represent services that should not be coded together based on anatomic, temporal, or gender considerations
If an encounter has codes from both columns, this creates an edit pair. If both codes from the edit pair are billed for the same beneficiary, same date of service, by the same performing provider, the Column 1 is eligible for payment and the Column 2 code is subject to denial as the service is considered integral.
Medical unlikely Edits
MUE are a different type of NCCI edit that began in 1/2007
Does not look at code combinations and bundling
Instead focuses on how many units are billed for a single CPT code
MUE are line item edits rather than claim level edits
If units of service exceed that allowed by the MUE, the entire line is denied
