This course 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 0.5000 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 0.5000 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
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.
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