Medicare's Outpatient Prospective Payment System: Calculating APC Payments

Outline:
Section 1: Introduction

About This Course

Learning Objectives

APC Payment Groups

Section 2: Rates

Determining APCs and APC Rates: Addendum A

Determining APCs and APC Rates: Addendum B

Determining APCs and APC Rates: Addendum M

Calculation of APC Rates and Weights

Review

Section 3: Calculations

Establishing the OPPS Conversion Factor

Rates Calculated from Weights

Use of Modifiers for Discontinued Services

Discounting

Review

Calculating Hospital-Specific Payments

Payment Rate Calculation

Example of Hospital Payment

Review

Section 4: Payments

OPPS Coinsurance

Deductible

Calculating Payments with Deductibles and Coinsurance

Outlier Payments

Sample Outlier Payment Calculation

Review

Section 5: Conclusion

Summary

Course Contributors

Resources

References

Richard has more than eighteen years in healthcare consulting. He has developed an expertise in hospital outpatient and inpatient coding, including professional split billing and E/M coding, admission criteria, reimbursement and compliance, and charge master reviews. His areas of expertise include Medicare reimbursement for the Medicare Outpatient Prospective Payment System (OPPS), Medicaid Ambulatory Payment Groups (APGs), as well as commercial payers, and professional reimbursement. He is a certified coder with AHIMA (CCS). Richard earned his Bachelors from Hobart College.

Disclosure: Richard R. Cooley, BA, CCS has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

Jean Russell has over thirty years of healthcare and information system experience. Her areas of expertise include the Medicare outpatient prospective payment systems (APCs, and APGs), as well as ICD-10-CM/PCS training, Charge Description Master (CDM), admission status reviews, and outpatient coding and compliance. She is a frequent speaker at the national, state and local levels for HFMA and AHIMA professional groups. Jean has her Masters from the University of Houston in Biomedical Engineering; her Bachelors from Colgate University in Biology; and her RHIT from the independent study program through the American Health Information Management Association.

Disclosure: Jean C. Russell, MS, RHIT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

Alison has twenty-nine years of healthcare and information system experience, eleven of those years consulting at hospitals across the United States. Her areas of expertise include all aspects of Soarian Financials Revenue Management including Service Catalog (CDM), Service Maps, CRDT, General Ledger, Contracts, Claims, Reports, and all Master Files. Alison has provided analysis and reconfiguration for optimization, new build services, legacy support for hospital systems moving to a new platform, and training.

Disclosure: Alison Kazmierczak has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.