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.
Members only summaries:
- Premier detailed summary of the CY 2016 Medicare outpatient PPS final rule
- Premier detailed summary of the CY 2016 Medicare outpatient PPS proposed rule
Members only excel files: comparing outpatient PPS payments proposed in 2016 to final payments in 2015
Members only summary: Premier detailed summary of the CY 2015 Medicare outpatient PPS final rule
Members only excel files: comparing outpatient PPS payments proposed in 2015 to final payments in 2014
Members only summary: Detailed summary of CY 2014 Outpatient PPS final rule
Members only excel files:
- Excel comparison file of CY 2014 outpatient PPS interim final rule – Addendum A
- Excel comparison file of CY 2014 outpatient PPS interim final rule – Addendum B