OPPS Payment Calculations

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HOPPS/ASC: Use the information found in figures 1–5 below to completethe OPPS payment calculations in table 1 and the ASC PPS payment calculationsin table 2. Determine the OPPS and ASC reimbursement rates for acataract procedure. Answer the discussionquestion.
  Click and download the exercise and the answer sheet.  Submit answer sheet via blacboard by or before 11/9/2015
 

Figure 1: HospitalInformation

Bedsize: Teachingstatus: Wage index:.9971  
300 beds Non-teaching  
Cost to Charge Ratios(CCRs)
RC250 Pharmacy,general 0.408344
RC270 Supplies,general 0.796788
RC271 Nonsterilesupply 0.796788
RC272 Sterilesupply 0.796788

 

 

RC276 Intraocularlens 0.796788
RC301 Chemistry 0.291546
RC312 Pathology,surgical 0.291546
RC360 Operatingroom 0.404314
RC370 Anesthesia 0.321246
RC710 Recoveryroom 0.404314
RC730 EKG 0.38251
RC920 Diagnosticservices 0.88447

 

 

Figure 2: Claim Information Hospital OutpatientDepartment

Admitdate 2/20/2015 Dischargedate 2/20/2015
Sex:F Age:70 LOS: 1day  
 
Admitdiagnosis 366.9 Cataract,unspecified
Principaldiagnosis: 366.10 Senile cataract,unspecified
Principalprocedure: 66984 Cataract extraction with IOLinsertion
ChargeDetail
RevenueCode CPT/HCPCSCode CodeDescription Charge
250     $475.25
270     $380.25
271     $1178.18
272     $1297.07
276     $551.00
301 36415 Routine venipuncture $10.00
301 82565 Assay ofcreatinine $33.75
301 84132 Assay ofserum potassium $33.75
301 85014 Hematocrit $34.75
312 88304 Tissue examby pathologist $83.50
360 66984 Cataractextraction w/IOL $801.33
370     $574.00
710     $341.00
730 93005 Electrocardiogram, tracing $124.50
920 90772 Ther/proph/diaginj, sc/im $75.50
TOTALCharges $5,693.83
Medicare beneficiary copaymentamount: $531.88

 

Figure 3: Claim Information Ambulatory SurgeryCenter

CPT Code:66984 Cataract extractionwith IOL Charges: $2,500.00
Medicare beneficiary copaymentamount: $192.76

 


Figure 4: Fee Schedule Information (CY 2012; to get current year seewww.cms.gov)

RevenueCode CPT/HCPCS FeeSchedule Amt StatusIndicator
301 36415 $3.00 A
301 82565 $7.26 A
301 84132 $6.51 A
301 85014 $3.35 A

 

 

Figure 5: APC Information (CY 2012; to get current year seewww.cms.gov)

RevenueCode CPTCode APC Relative Weight StatusIndicator
312 88304 0343 0.5262 X
360 66984 0246 23.8786 T
730 93005 0099 0.3823 S
920 90772 0436 1.8104 S
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