This lesson explains the Outpatient Prospective Payment System (OPPS) payment provisions, focusing primarily on the calculation of adjusted Ambulatory Payment Classification (APC) amounts, taking into consideration such things as coinsurance, deductibles, and geographic adjustments.
“This program has been approved for 0.50 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
This activity is approved for 0.50 contact hours.
Section 1: Introduction
About This Course
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
Section 3: Calculations
Establishing the OPPS Conversion Factor
Rates Calculated from Weights
Use of Modifiers for Discontinued Services
Calculating Hospital-Specific Payments
Payment Rate Calculation
Example of Hospital Payment
Section 4: Payments
Calculating Payments with Deductibles and Coinsurance
Sample Outlier Payment Calculation
Section 5: Conclusion
Expert Reviewer: Jean C. Russell, MS, RHIT
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.
Instructor: Alison Kazmierczak
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.
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