(Medicare Claims Processing Manual)

Refer to https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html  for the most current OPPS APC Offset File.   50.4  Changes to Pricer Logic Effective April 1, 2002  (Rev. 11941, Issued:04 -05-23, Effective: 04 -01-02, Implementation: 05- 05-23)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.  A. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.   B. Inpatient hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.  C. Section 401 designations and floor MSA designations will be considered effective for OPPS on April 1, 2002.   D. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002, except those 55 APCs with coinsurance amounts limited to 55 percent of the payment rate, which were effective January 1, 2002.  The coinsurance limit equal to the inpatient  deductible of $812 remains effective January 1, 2002.  E. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.   F. If a claim has more than 1 service with a status indicator (SI) of S or T and any lines with SI of S or T have less than $1.01 as charges, charges for all S and/or T lines will be summed and the charges will then be divided up proportionately to the payment rate for each S or T line.  The new charge amount will be used in place of the submitted charge amount in the line item outlier calculation.   EXAMPLE:   SI Charges  Payment Rate New Charges Amount  S $19,999 $6,000 $12,000 T $1 $3,000 $6,000 S $0 $1,000 $2,000  $20,000 $10,000 $20,000  Because total charges here are $20,000 and the first SI of S gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 * $20,000 = $12,000.  G. All charges on lines with a SI of N (bundled services) on the claim will be summed and the charges will then be divided up proportionately to the payment rate for each S, T, V or X line.  This proportional amount will be added to the new charges amount from item F above or, if that doesn't apply, they will be added to the actual submitted charges for each S, T, V or X before making a line item outlier calculation.   H. Outliers will be calculated at a line item level.  No outlier payment will be calculated for SIs of G, K, N or H, although charges for packaged services (SI=N) will be used in calculating outlier payments for other services as described in G. above.  Price r will use submitted charges as modified by items F and G above.  The CMS changed the factor multiplied times the total claim payments from 2.5 to 3.5 and factor used to multiply the difference between claim payments and costs from .75 to .50.  Pricer will  keep the cost to charge ratio adjustment factor at .981956.  Pricer will sum all line item outlier amounts and output them as a single total claim outlier amount, just as it outputs the outlier amount that contractors are to place in value code 17.   I. Any claim with one or more APCs that match those listed in Table 1 of the March 1, 2002,  Federal Register will have all applicable APC offset amounts summed and wage adjusted.  The total wage adjusted offset amount will be subtracted proportionately from the charges reduced to costs for any SI H devices that have a HCPCS code beginning with a C, i.e., C1713 through C2631.  J. A pro rata reduction of 63.6 percent applies to all SI G and/or H payments.  For H, devices, the offset (or reduction) is applied to the final payment amount after  all device offset amounts (see item I  above) have been taken.  For SI G, pass thru drugs, CMS determines the pass -through amount (PTA) by subtracting 5 times the minimum coinsurance from the Medicare payment amount.  The CMS will multiply .364 times the PTA and add that amount to 5 times the minimum coinsurance to get the new Medicare payment amount.   K. The provider specific file for SNFs and HHAs that may be reimbursed for splints, casts and/or antigens under OPPS should have a cost to charge ratio of 0.000 (or 0.001 if the shared system will not allow 0.000.  Pricer will not pay outliers for these servi ces.  L. Pricer Drug Copayment Changes   M. APC  N. Drug Name  O. Corrected Copayment  P. 726 Q. Dexrazoxane  R. $27.85 S. 1607 T. Eptifibatide  U. $1.62  50.5 - Changes to Pricer Logic Effective April 1, 2002  (Rev.  11941, Issued:04- 05-23, Effective: 04 -01-02, Implementation: 05- 05-23)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.  V. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.   W. Inpatient hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.  X. Section 401 designations and floor MSA designations will be considered effective for OPPS on April 1, 2002.   Y. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002, except those 55 APCs with coinsurance amounts limited to 55 percent of the payment rate, which were effective January 1, 2002.  The coinsurance limit equal to the inpatient  deductible of $812 remains effective January 1, 2002.  Z. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.   AA.  If a claim has more than 1 service with a status indicator (SI) of S or T and any lines             with SI of S or T have less than $1.01 as charges, charges for all S and/or T lines will be summed and the charges will then be divided up proportionately t o the payment rate for each S or T line.  The new charge amount will be used in place of the submitted charge amount in the line item outlier calculation.  EXAMPLE:   SI Charges  Payment Rate New Charges Amount  S $19,999 $6,000 $12,000 T $1 $3,000 $6,000 S $0 $1,000 $2,000 SI Charges  Payment Rate New Charges Amount   $20,000 $10,000 $20,000  Because total charges here are $20,000 and the first SI of S gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 * $20,000 = $12,000.  BB. All charges on lines with a SI of N (bundled services) on the claim will be summed and the charges will then be divided up proportionately to the payment rate for each S, T, V or X line.  This proportional amount will be added to the new charges amount from item F above or, if that doesn't apply, they will be added to the actual submitted charges for each S, T, V or X before making a line item outlier calculation.   CC. Outliers will be calculated at a line item level.  No outlier payment will be calculated for SIs of G, K, N or H, although charges for packaged services (SI=N) will be used in calculating outlier payments for other services as described in G. above.  Pricer will use submitted charges as modified by items F and G above.  The CMS changed the factor multiplied times the total claim payments from 2.5 to 3.5 and factor used to multiply the difference between claim payments and costs from .75 to .50.  Pricer will keep the cost to charge ratio adjustment factor at .981956.  Pricer will sum all line item outlier amounts and output them as a single total claim outlier amount, just as it outputs the outlier amount that contractors are to place in value code 17.  DD. Any claim with one or more APCs that match those listed in Table 1 of the March 1, 2002,  Federal Register will have all applicable APC offset amounts summed and wage adjusted.  The total wage adjusted offset amount will be subtracted proportionately from the charges reduced to costs for any SI H devices that have a HCPCS code beginning with a C, i.e., C1713 through C2631.  EE.       A pro rata reduction  of 63.6 percent applies to all SI G and/or H payments.  For H, devices, the offset (or reduction) is applied to the final payment amount after all device offset amounts (see item I  above) have been taken.  For SI G, pass thru drugs, CMS determines the pass -through amount (PTA) by subtracting 5 times the minimum coinsurance from the Medicare payment amount.  The CMS will multiply .364 times the PTA and add that amount to 5 times the minimum coinsurance to get the new Medicare payment amount.   FF.      The provider specific file for SNFs and HHAs that may be reimbursed for splints, casts and/or antigens under OPPS should have a cost to charge ratio of 0.000 (or 0.001 if the shared system will not allow 0.000.  Pricer will not pay outliers for these servi ces.  GG. Pricer Drug Copayment Changes   HH. APC  II. Drug Name  JJ. Corrected Copayment  KK. 726 LL. Dexrazoxane  MM. $27.85 NN. 1607 OO. Eptifibatide  PP. $1.62  50.6 - Changes to the OPPS Pricer Logic Effective January 1, 2003  (Rev. 1, 10- 03-03)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning January 1, 2003.   A. New OPPS wage indexes will be effective January 1, 2003.  These are the same wage indexes that were implemented on October 1, 2002, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule and CMS are using the corrected wage indexes where applicable.   B. Inpatient hospitals considered reclassified on October 1, 2002, will be considered reclassified for OPPS on January 1, 2003.   C. Section 301 designations and floor MSA designations will be considered effective for OPPS on January 1, 2003.  D. New payment rates and coinsurance amounts will be effective for OPPS on January 1, 2003.  Some APCs have coinsurance amounts limited to 55 percent of the payment rate effective January 1, 2003.  Some APCs have a coinsurance limit equal to the inpatient deductible of $840 effect ive January 1, 2003.  E. If a claim has more than 1 service with a status indicator (SI) of T (SI of S has been  removed from this rule) and any lines with SI T have less than $1.01 as charges, charges for all T lines will be summed and the charges will then be divided up proportionately to the payment rate for each T line.  The new charge amount will be used in plac e of the submitted charge amount in the line item outlier calculation.   EXAMPLE:   SI Charges  Payment Rate New Charges Amount  T $19,999 $6,000 $12,000 T $1 $3,000 $  6,000 SI Charges  Payment Rate New Charges Amount  T $0 $1,000 $  2,000  $20,000 $10,000 $20,000  Because total charges here are $20,000 and the first SI of T gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 x $20,000 = $12,000.