(Medicare Claims Processing Manual)

Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the total charges to cost by multiplying them by the outpatient cost -to-charge r atio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments (including reconciled outlier payments and the time value of money) and transitional pass -through payments  for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result of step 1, go to step 4.  No transitional payment is due this month.   Step 3 -  If the hospital is a childrens hospital, a rural hospital with 100 or fewer beds, or a sole community hospital (including EACHs), subtract the result of step 2 from the result of step 1 and pay .85 times this amount.  If the hospital is not one of the hospital types listed above, no payment is made.   Step 4 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of step 1 for any other month, store all step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.   70.8 - TOPs Overpayments (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)  Because the revised TOP calculations are often implemented in the system after their effective date, overpayments or underpayments in interim TOPs to providers are expected.   Unless directed by CMS, retroactive calculations of monthly interim TOP amounts are not necessary because any difference in interim TOP payments and actual TOP amounts determined on the cost report will be taken into account in the cost report settlement process, including tentative settlements.   If mutually agreed upon by both the contractor and the provider, the contractor can pay less than 85 percent of the monthly TOP payment to that provider, to avoid significant overpayments throughout the year that must be paid back to the contractor at cost  report settlement.   Contractors should advise providers of the revised TOP calculations and other changes in OPPS using their normal communication protocols (Web site, regularly scheduled bulletins, electronic bulletin boards, or listserv).   80 - Shared system Requirements to Incorporate Provider -Specific Payment -to-Cost Ratios into the Calculation of Interim Transitional Outpatient Payments Under OPPS  (Rev. 1, 10- 03-03) A-01-44  80.1 - Background - Payment -to-Cost Ratios (Rev. 1060, Issued: 09 -18-06, Effective: 10 -01-06, Implementation: 10- 02-06)  Under regulations at 42 CFR 419.70, hospitals and community mental health centers (CMHCs) that are subject to the OPPS may be eligible to receive a transitional corridor payment, frequently referred to as a TOP.  The purpose of the TOP is to restore some of the decrease in the payment that  a provider may experience under the OPPS.  Providers that are eligible for TOPs receive monthly interim payments.  However, the final TOP amount is calculated based on the providers settled cost report.  Final TOP payments for a calendar year are based o n the difference between what the provider was paid under the OPPS, and the providers pre -Balanced Budget Act (BBA) amount.  The pre -BBA amount is an estimate of what the provider would have been paid during the calendar year for the same services under  the system that was in effect prior to OPPS.  If the pre -BBA amount exceeds the actual OPPS payments a provider received during a calendar year, qualifying cancer centers and childrens hospitals are permanently held harmless, and will receive the entire amount of the difference between their OPPS payments and their pre -BBA amount.  Other hospitals and CMHCs may receive a portion of the difference as a TOP, depending on the rules listed above.   The pre -BBA amount is calculated by multiplying the providers PCR, based on the providers base year cost report, times the reasonable costs the provider incurred during a calendar year to furnish the services that were paid under the OPPS.  For most hospitals and CMHCs, the base year cost report used to calculate the payment -to-cost ratio is the cost report that ended during calendar year 1996.  However, if a hospital or CMHC did not file a cost report that ended in calendar year 1996, the payment -to cost  ratio will be calculated using the providers first cost report that ended after calendar year 1996 and before calendar year 2001.   80.2 - Using the Newly Calculated PCR for Determining Final TOP Amounts  (Rev. 1, 10- 03-03) A-01-44  Final TOP amounts are determined for each calendar year, based on the calendar year or portion of a calendar year that falls within a providers cost reporting period.  The PCR is one factor used on Worksheet E, Part B, of the hospital cost report (Form CM S-2552 -  96), and Worksheet J -3 of the CMHC cost report (Form CMS -2088) in calculating the providers final TOP amount.  Once calculated, the providers PCR will be used to calculate the providers pre-  BBA amount for all calendar years for which the provider may be eligible for a TOP payment.  The PCR will not change each year.   80.3 - Using the Newly Calculated PCR for Determining Interim TOPs  (Rev. 1060, Issued: 09- 18-06, Effective: 10 -01-06, Implementation: 10- 02-06)  Providers that are eligible for TOPs receive monthly interim payments.  Initially, the calculation of the monthly payment used a national uniform PCR of 80 percent for all providers.  After A/B MACs (A) calculated a provider -specific PCR, no later than October 1, 2001, that PCR shall be used in calculating monthly interim payments to the provider.  The shared systems maintainers will populate the PCR field of the Provider Specific File (formerly cost- of-living adjustment field) to reflect the provider -speci fic PCR.   The shared systems maintainers will revise the monthly TOPs calculation to use the provider -specific PCR, taken from the Provider Specific File, in lieu of the national PCR of 80 percent.  If the value in the PCR field in the Provider Specific File is blank (i.e., the A/B MAC (A) has not yet calculated a provider -specific PCR), the A/B MAC (A) must immediately calculate a provider -specific PCR and cannot continue to use the national PCR of 80 percent.  The change to the provider -specific file and the change  in the calculation of TOPs payments were effective on July 1, 2001.  90 - Discontinuation of Value Code 05 Reporting  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01-01-08; Implementation Date:  01-04-10)  Value code 05, Professional Component Included in Charges and Also Billed Separately to Carrier, was discontinued with the implementation of OPPS, including claims for Critical Access Hospitals and other hospitals not subject to OPPS.   100 - Medicare Summary Notice (MSN)  (Rev. 1, 10- 03-03)  Effective for claims with dates of service on or after August 1, 2000, A/B MACs (A) must modify the MSN for services provided by providers under OPPS to reflect the addition of an APC number.  This APC number should be placed next to the HCPCS code include d under the Services Provided column, and must be within a parenthesis.  The coinsurance column should reflect the coinsurance amount for which the beneficiary is responsible.  In addition, the back of the notice must be modified.  In place of the current language, the notice should reflect the following language:   THE AMOUNT YOU MAY BE BILLED for Part B services includes:   Annual deductible, the first $100 of Medicare Part B charges each year;   After the deductible has been met for the year, depending on services received, a coinsurance amount  (20 percent of the amount charged), or a fixed copayment  for each service; and   Charges for services or supplies that are not covered by Medicare.  You may not have to pay for certain denied services.  If so, a note on the front will tell you.  The Spanish version should read as follows:   La cantidad por la cual usted podra ser facturado incluye:   Un deducible anual, los primeros $100 de Medicare Parte B de cargos aprobados cada ao, Despus de que haya cumplido con el deducible, dependiendo de los servicios recibidos, un coaseguro (20% de la cantidad cobrada), o un copago fijo por cada servicio ; y   Cargos por servicios/suministros que no estn cubiertos por Medicare.  Es posible que usted no tenga que pagar por ciertos cargos se servicios denegados.  De ser el caso, una NOTA en la parte del frente le indicar.   Also, A/B MACs (A) print the following message in the General Information Section:   If the coinsurance amount you paid is more than the amount shown on your notice, you are entitled to a refund.  Please contact your provider.   Spanish Version:   Si la cantidad de coaseguro que usted pag es mayor que la cantidad que muestra su notificacin, tiene derecho a un reembolso.  Por favor comunquese con su proveedor.   110 - Procedures for Submitting Late Charges Under OPPS  (Rev. 1, 10- 03-03) A-01-93  Hospitals and CMHCs may not submit a late charge bill (code 5 in the third position of the bill type) for bill types 12X, 13X, 14X, and 76X effective for claims with dates of service on or after August 1, 2000.  They must submit an adjustment bill for any services required to be billed with HCPCS codes, units and line item dates of service.  A 7 in the third position of the bill type indicates an adjustment.  See Chapter 25 for additional instructions for reporting adjustments.  Separate bills containing only late charges will not be permitted for these bill types.  The submission of an adjustment bill, instead of a late charge bill, will ensure proper duplicate detection, bundling, correct application of coverage policies and proper editing by OCE and payment under OPPS.  120 - General Rules for Reporting Outpatient Hospital Services  (Rev. 3019, Issued: 08- 07-14, Effective: 01 -01-12, ICD -10: Upon Implementation of ICD-  10, Implementation: 09- 08-14, ICD -10: Upon Implementation of ICD - 10)   Hospitals use the electronic ASC X12 837 institutional claim transaction format or the hardcopy Form CMS -1450 to bill for covered outpatient services (type of bill 13X or 83X, and 85X).  The ASC X12 837 institutional claim transaction is required unless the hospital meets certain exception criteria.  These criteria are described in Chapter 24, 90- 90.5.4 of this manual.  See:   Medicare Benefit Policy Manual, Chapter 6, for definition of an outpatient;   Medicare Claims Processing Manual, Chapter 3, Inpatient Part A Hospital Billing, for outpatient services treated as inpatient services;   Medicare Claims Processing Manual Chapter 24, 90- 90.5.4 for when paper billing is permissible; and   Medicare Claims Processing Manual, Chapter 25, for general instructions for completing the hospital claim data set.   The HCPCS code is used to describe services where payment is under the Hospital OPPS or where payment is under a fee schedule or other outpatient payment methodology.  Line item dates of service are reported for every line where a HCPCS code is required under OPPS.  For providers paid via OPPS, A/B MACs (A) return to provider (RTP) bills where a line item date of service is not entered for each HCPCS code reported, or if the line item dates of service reported are outside of the statement -covers period.  This includes those claims where the from and through dates are equal.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims on TOB 83X for ASCs.  All IHS ASC providers must submit their claims to the designated A/B MAC (B).   120.1 - Bill Types Subject to OPPS  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    The following bill types are subject to OPPS: