Healthcare Reimbursement 530-185 OPPS Skill Assessment PART A: Describe the step

Question

Healthcare Reimbursement 530-185 OPPS Skill Assessment PART A: Describe the steps in calculating Hospital Outpatient PPS payment (25 points): Click here to enter text PART B: For each of the given Case Studies, complete the table and corresponding questions if applicable. Enter your answers in the space or box provided (25 points each case Case 1: A 73 year old Medicare patient was seen in the Senior Health clinic for a monthly appointment to evaluate hypertension. The patient is seen by the nurse practitioner, who checks the patient's blood pressure, evaluates the current medication dosage, and performs a limited examination. She reports the findings to the physician. The patient's medication is adjusted and the patient is sent home. The physician did not see the patient CPT Code(s): 99211 E&M;, office, established patient not requiring presence of MD CPT CODE APC WEIGHTSI 99211 If any modifiers (or NIA): DISCOUNTING HIGHEST PAYING (Y OR N) CPT CODE 1. Definition of the modifier 2. If or how it affects reimbursement:

Explanation / Answer

Step 1

Determine the Ambulatory Payment Classifications (APCs) among which the patient's charges belong. Then verify the APCs payment for the hospital by taking adjusted national weight based on the geographic factor for the hospital.

Step 2

Confirm the outlier payment threshold, by multiplying the APC amount payable to the hospital for that patient by 2.5. (2.5% of total HOPPS payments as Congress instructed).

Step 3                                                                                                  

Determine the grand total of charges by adding up all of the charges on that patient's claim

The costs of providing the care to that particular patient are calculated by multiplying the gross charges on the claim by the hospital's ratio of costs to charges.

Step 4

If the adjusted cost is greater than the APC outlier threshold amount then outlier payment is supported.

Step 5

Subtract the outlier threshold amount (2.5 x APC) from the calculated cost for the patient involved to determine the "excess cost."

In addition to the APC payment amount, 75% of the excess cost will be paid by HCFA.

Case 1.

In order to get maximum payment, a nurse should spend at least 10 minutes with the patient. Collect a

                        Modifiers: problem focused history, examination, a clear medical decision making

                        Case 2:

                       

                       

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