OPPS Payment Worksheet bPPS/ASC: Use the information found in figures 1-5 below to complete the OPPS payment calculations in table 1 and the ASC PPS payment calculations in table 2. Determine the OPPS and ASC reimbursement rates for a cataract procedure. Then answer the discussion question. Wage index: .9971 Figure 1: Hospital Information Bed size: Teaching status: 300 beds Non-teaching Cost to Charge Ratios (CCRs) RC 250 Pharmacy, general RC 270 Supplies, general RC 271 Nonsterile supply RC 272 Sterile supply RC 276 Intraocular lens RC 301 Chemistry RC 312 Pathology, surgical RC 360 Operating room RC 370 Anesthesia RC 710 Recovery room RC 730 EKG RC 920 Diagnostic services 0.408344 0.796788 0.796788 0.796788 0.796788 0.291546 0.291546 0.404314 0.321246 0.404314 0.38251 0.88447 Figure 2: Claim Information Hospital Outpatient Department Admit date 2/20/2013 Discharge date Sex: F Age: 70 LOS: 1 day 2/20/2013 Cataract, unspecified Senile cataract, unspecified Cataract extraction with IOL insertion Code Description Admit diagnosis 366.9 Principal diagnosis: 366.10 Principal procedure: 66984 Charge Detail Revenue Code CPT/HCPCS Code 250 270 271 272 276 301 36415 301 82565 301 84132 charge $475.25 $280.25 $1178.18 $1297.07 $351.00 $10.00 $33.75 $33.75 301 312 85014 88304 Routine venipuncture Assay of creatinine Assay of serum potassium Hematocrit Tissue exam by pathologist Cataract extraction w/IOL $34.75 $83.50 360 66984 $801.33 370 710 $574.00 $341.00 $124.50 730 920 $75.50 93005 Electrocardiogram, tracing 90772 Ther/proph/diagini, sc/im TOTAL Charges Medicare beneficiary copayment amount: $5,693.83 $531.88 Figure 3: Claim Information Ambulatory Surgery Center CPT Code: 66984 Cataract extraction with IOL Medicare beneficiary copayment amount: charges:$2,500.00 $192.76 Figure 4: Fee Schedule Information (CY 2012; to get current year see www.cms.gov) Revenue Code CPT/HCPCS Fee Schedule Status Indicator Amt 301 36415 $3.00 A 301 B2565 $7.26 A 301 B4132 $6.51 A 301 85014 $3.35 A Figure 5: APC Information (CY 2012; to get current year see www.cms.gov) Revenue Code CPT Code APC Relative Weight Status Indicator 312 88304 0343 0.5262 X 360 66984 0246 23.8786 730 93005 0099 0.3823 5 920 90772 0436 1.8104 5 HOPPS Payment Determination Steps Step One: Calculate APC payment rate(s) Step Two: Wage index adjust APCs Step Three: Sum of fees for status indicator A procedures Step Four: Sum of reasonable cost amount(s)[only applicable for CPT/HCPCS codes with status indicators Land H) Step Five: Sum Medicare payments Table 1 Step Methodology Total One APC relative weight conversion factor ($70.01) TWO (APC pymt rate* .60*WI) + (APC pymt rate 40) Three Fee schedule amount A+ fee schedule amount B, etc. Four (Charge * CCR) Five TOTAL Reimbursement - Sum of steps 2-4 ASC Payment Determination Steps Step One: Calculate APC payment rate(s) Step Two: Wage index adjust APCs Step Three: Calculate the APC payment rate for any allowed secondary procedures Step Four: Wage index adjust allowed secondary procedure APCs Step Five: Sum Medicare payments Table 2 Step One Total Methodology APC relative weight conversion factor ($42.63) TWO (APC pymt rate 50*WI) + (APC pymt rate ..50) Three APC relative weight conversion factor ($41.401) Four (APC pymt rate* 50*WI) + (APC pymt rate 50) Five TOTAL Reimbursement - Sum of steps 2-4 Discussion Question: Discuss the parity and disparity between the payment levels at the ASC and Hospital-based surgery center. Why is parity and disparity an important topic to discuss? How does it affect the average Medicare beneficiary? OPPS Payment Worksheet bPPS/ASC: Use the information found in figures 1-5 below to complete the OPPS payment calculations in table 1 and the ASC PPS payment calculations in table 2. Determine the OPPS and ASC reimbursement rates for a cataract procedure. Then answer the discussion question. Wage index: .9971 Figure 1: Hospital Information Bed size: Teaching status: 300 beds Non-teaching Cost to Charge Ratios (CCRs) RC 250 Pharmacy, general RC 270 Supplies, general RC 271 Nonsterile supply RC 272 Sterile supply RC 276 Intraocular lens RC 301 Chemistry RC 312 Pathology, surgical RC 360 Operating room RC 370 Anesthesia RC 710 Recovery room RC 730 EKG RC 920 Diagnostic services 0.408344 0.796788 0.796788 0.796788 0.796788 0.291546 0.291546 0.404314 0.321246 0.404314 0.38251 0.88447 Figure 2: Claim Information Hospital Outpatient Department Admit date 2/20/2013 Discharge date Sex: F Age: 70 LOS: 1 day 2/20/2013 Cataract, unspecified Senile cataract, unspecified Cataract extraction with IOL insertion Code Description Admit diagnosis 366.9 Principal diagnosis: 366.10 Principal procedure: 66984 Charge Detail Revenue Code CPT/HCPCS Code 250 270 271 272 276 301 36415 301 82565 301 84132 charge $475.25 $280.25 $1178.18 $1297.07 $351.00 $10.00 $33.75 $33.75 301 312 85014 88304 Routine venipuncture Assay of creatinine Assay of serum potassium Hematocrit Tissue exam by pathologist Cataract extraction w/IOL $34.75 $83.50 360 66984 $801.33 370 710 $574.00 $341.00 $124.50 730 920 $75.50 93005 Electrocardiogram, tracing 90772 Ther/proph/diagini, sc/im TOTAL Charges Medicare beneficiary copayment amount: $5,693.83 $531.88 Figure 3: Claim Information Ambulatory Surgery Center CPT Code: 66984 Cataract extraction with IOL Medicare beneficiary copayment amount: charges:$2,500.00 $192.76 Figure 4: Fee Schedule Information (CY 2012; to get current year see www.cms.gov) Revenue Code CPT/HCPCS Fee Schedule Status Indicator Amt 301 36415 $3.00 A 301 B2565 $7.26 A 301 B4132 $6.51 A 301 85014 $3.35 A Figure 5: APC Information (CY 2012; to get current year see www.cms.gov) Revenue Code CPT Code APC Relative Weight Status Indicator 312 88304 0343 0.5262 X 360 66984 0246 23.8786 730 93005 0099 0.3823 5 920 90772 0436 1.8104 5 HOPPS Payment Determination Steps Step One: Calculate APC payment rate(s) Step Two: Wage index adjust APCs Step Three: Sum of fees for status indicator A procedures Step Four: Sum of reasonable cost amount(s)[only applicable for CPT/HCPCS codes with status indicators Land H) Step Five: Sum Medicare payments Table 1 Step Methodology Total One APC relative weight conversion factor ($70.01) TWO (APC pymt rate* .60*WI) + (APC pymt rate 40) Three Fee schedule amount A+ fee schedule amount B, etc. Four (Charge * CCR) Five TOTAL Reimbursement - Sum of steps 2-4 ASC Payment Determination Steps Step One: Calculate APC payment rate(s) Step Two: Wage index adjust APCs Step Three: Calculate the APC payment rate for any allowed secondary procedures Step Four: Wage index adjust allowed secondary procedure APCs Step Five: Sum Medicare payments Table 2 Step One Total Methodology APC relative weight conversion factor ($42.63) TWO (APC pymt rate 50*WI) + (APC pymt rate ..50) Three APC relative weight conversion factor ($41.401) Four (APC pymt rate* 50*WI) + (APC pymt rate 50) Five TOTAL Reimbursement - Sum of steps 2-4 Discussion Question: Discuss the parity and disparity between the payment levels at the ASC and Hospital-based surgery center. Why is parity and disparity an important topic to discuss? How does it affect the average Medicare beneficiary