Medicare Outpatient Prospective Payment System
INTRODUCTION
The Blue Cross and Blue Shield Association (Association)
on behalf of the Health Care Financing Administration (HCFA) developed
this Medicare Outpatient Prospective Payment System (OPPS) training session.
The training session has been prepared to assist providers and Medicare
fiscal intermediaries (FIs) with the information they will need to know
in order to successfully implement the new payment system.
This session and the training publication are designed
for training individuals who will in turn, train providers and FI staff
in OPPS. We have provided training text, overhead slides, and reference
documents to facilitate that process.
This training publication was initially produced prior
to the publication of the final rule implementing Medicare’s Outpatient
Prospective Payment System. We have revised the training material to incorporate
the best information available at the time of publication. Please refer
to the final rule as published in the Federal Register for authoritative
guidance in the new system.
This publication should not be considered an authoritative
source in making Medicare Program policy determinations.
COURSE OBJECTIVES
At the end of this session participants will be able
to:
- Explain (at a conceptual level) the basic components
of OPPS
- Explain (at a conceptual level) how the components
of OPPS interact from claim submission to finalization using program
materials developed for provider training
- Understand the impact of OPPS on FI workload and
work flow , as well as the impact on audit and reimbursement
- Understand the fiscal intermediary (FI) responsibilities
related to OPPS provider education and anticipated provider concerns
- Understand how to use the training tools developed
for this course to help address provider OPPS education
CERTIFICATION
This training course meets the Continuing Education
and Training (CET) requirements of the Government Auditing Standards and
should qualify for CET credit by your state Board of Accountancy,
since Blue Cross and Blue Shield Association is a corporate sponsor in
the state of Illinois and an approved sponsor in the National
Association of State Boards of Accountancy, National Registry of
CPE Sponsors (91-00149-99).
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Registered with the National Association of
State Boards of Accountancy as a sponsor of continuing professional
education on the National Registry of CPE Sponsors. State boards
of accountancy have final authority on the acceptance of individual
courses.
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Complaints regarding registered sponsors may be
addressed to NASBA, 380 Lexington Avenue, New York, NY 10168-0002,
1-212-490-3868.
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APG
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Ambulatory Patient Group
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APASS
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Arkansas Part A Standard System
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APC
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Ambulatory Payment Classification
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ASC
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Ambulatory Surgical Center
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BBA
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Balanced Budget Act of 1997
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BBRA
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Balanced Budget Refinement Act of 1999 (per
OPPS PM)
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CAH
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Critical Access Hospital
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CC
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Condition Code
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CCI
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Correct Coding Initiative
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CELIP
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Claim Expansion and Line Item Pricing
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CFR
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Code of Federal Regulations
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CMHC
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Community Mental Health Center
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CORF
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Comprehensive Outpatient Rehabilitation Facility
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CPT
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Current Procedural Terminology
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DME
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Durable Medical Equipment
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E&M
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Evaluation and Management
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EOMB
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Explanation of Medicare Benefits
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ERA
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Electronic Remittance Advice
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FI
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Fiscal Intermediary
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FISS
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Fiscal Intermediary Shared System
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FMR
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Focused Medical Review
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F.R.
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Final Rule
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HCFA
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Health Care Financing Administration
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HCPCS
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HCFA Common Procedure Coding System
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HHA
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Home Health Agency
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ICD-9-CM
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International Classification of Disease, Clinical
Modification
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MR
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Medical Review
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MSN
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Medicare Summary Notice
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NDC
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National Drug Code
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OCE
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Outpatient Code Editor
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OPPS
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Outpatient Prospective Payment System
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PHP
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Partial Hospitalization Program
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PPS
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Prospective Payment System
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SPR
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Standard Paper Remittance
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SSA
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Social Security Act
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TOP
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Transitional Outpatient Payment
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VC
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Value Code
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