OPPS/ASC Reimbursement Comparison for Cataract Surgery

Part I: Use the information found in Figures 15 (below) and the textbook to complete the OPPS payment calculations in Table 1 and the ASC PPS payment calculations in Table 2. The 2015 OPPS conversion factor is $74.17. The 2015 ASC PPS conversion factor is $44.07.

Figure 1: Hospital Information

Bed size:	Teaching status:	Wage index: .9971
300 beds	Non-teaching
Cost to Charge Ratios (CCRs)
RC 250	Pharmacy, general	0.408344
RC 270	Supplies, general	0.796788
RC 271	Nonsterile supply	0.796788
RC 272	Sterile supply	0.796788
RC 276	Intraocular lens	0.796788
RC 301	Chemistry	0.291546
RC 312	Pathology, surgical	0.291546
RC 360	Operating room	0.404314
RC 370	Anesthesia	0.321246
RC 710	Recovery room	0.404314
RC 730	EKG	0.38251
RC 920	Diagnostic services	0.88447

Figure 2: Claim Information Hospital Outpatient Department

Admit date	2/20/2015	Discharge date	2/20/2015
Sex: F	Age: 70	LOS: 1 day
Admit diagnosis	366.9	Cataract, unspecified
Principal diagnosis:	366.10	Senile cataract, unspecified
Principal procedure:	66984	Cataract extraction with IOL insertion
Charge Detail
Revenue Code	CPT/HCPCS Code	Code Description	Charge
250			$475.25
270			$380.25
271			$1178.18
272			$1297.07
276			$551.00
312	88304	Tissue exam by pathologist	$83.50
360	66984	Cataract extraction w/IOL	$2,801.33
370			$574.00
710			$341.00
730	93005	Electrocardiogram, tracing	$124.50
920	96372	Ther/proph/diag inj, sc/im	$75.50
TOTAL Charges			$7,881.58

Figure 3: Claim Information Ambulatory Surgery Center

CPT Code: 66984	Cataract extraction with IOL	Charges: $3,500.00
TOTAL Charges		$3,500.00

Figure 4: OPPS Addendum B (Payment) Information

CPT Code	Status Indicator*	APC	APC Relative Weight	Copayment Amount
66984	T	233	23.6288	$350.53
88304	Q1	342	0.7318	$10.86
93005	Q1	99	1.0579	$15.70
96372	S	437	0.7218	$10.71

* OPPS Status Indicator meaning are located in Table 7.13 in the textbook

Figure 5: ASC Addendum AA (Payment) Information

CPT Code	Status Indicator	Relative Weight	CMS Payment Amount	Copayment Amount
66984	A2	21.7976	80% Payment Rate	20% Payment Rate

Table 1: OPPS Reimbursement

Step	Methodology	Total
A	Adjust for geographic factors
B	Adjust for complexity of service (complete for each separately payable service)
C	Apply OPPS provisions if applicable
D	NO OUTLIER for this example
E	TOTAL Reimbursement

Table 2: ASC PPS Reimbursement

Step	Methodology	Total
A	Adjust for geographic factors
B	Adjust for complexity of service
C	TOTAL Reimbursement