Important Notice: Our web hosting provider recently started charging us for additional visits, which was unexpected. In response, we're seeking donations. Depending on the situation, we may explore different monetization options for our Community and Expert Contributors. It's crucial to provide more returns for their expertise and offer more Expert Validated Answers or AI Validated Answers. Learn more about our hosting issue here.

How does the department calculate payments for covered outpatient services through the outpatient prospective payment system (OPPS)?

0
Posted

How does the department calculate payments for covered outpatient services through the outpatient prospective payment system (OPPS)?

0

(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

What is your question?

*Sadly, we had to bring back ads too. Hopefully more targeted.