OPPS and ASC rules

Introduction

The outpatient prospective payment system (OPPS) reimburses Medicare providers a pre-set amount by service. Each January 1, the weights associated with the Ambulatory Payment Classifications (APCs) are revised based upon updated median cost data. That weight is multiplied by a conversion factor (set dollar amount) that has been adjusted for differences in labor costs in the area to yield a base payment rate. Providers may bill for more than one APC per encounter. For example, a visit code might be billed with a separately payable drug code and an imaging code. However, many items and services are packaged within the APCs to which they are integral, such as contrast with imaging services or drugs below $60 with surgeries. There are also a minimal number of composite APCs that provide one payment for several major services such as partial hospitalization for mental health services. The APCs are adjusted to reflect geographic wage variation as under the inpatient payment system and are intended to cover both operating and capital costs.

Calculators

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CY 2013 OPPS

Final CY 2013 OPPS rule

Summary of final CY 2013 OPPS rule

Proposed CY 2013 OPPS rule

Summary of CY 2013 OPPS rule

Premier Flash Update on proposed CY 2013 OPPS rule

Excel files comparing OPPS APCs and payments in 2010 to proposed payments in 2011 (a description of the file is contained in the last worksheet in each Excel spreadsheet)

Comparison of Addenda A (list of APCs)

CY 2012 OPPS

CY 2011 OPPS

CY 2010 OPPS

 

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