Reimbursement Information

View facility level Medicare reimbursement information about your code.

Procedure

1. Perform a CPT/HCPCS code search.
2. Click the Reimbursement icon from the icon bar. The Reimbursement detail page opens.
3. In the Options section, Fac is selected by default.
4. Select a Facility Version.
5. Click Submit. Results display below the Options section. Your selected facility is in the header bar.

You can select up to 10 facilities to view reimbursement in a side-by-side display.

Procedure

1. From the Reimbursement Detail Page > Options, select Fac.
2. Click in the toolbar. A window displays listing all facilities assigned to your user name.
3. Select the check box for up to 10 facilities.
4. Click . Results display on the Reimbursement detail page under the Options section.

Professional reimbursement information is for your Geographical Practice Cost Index (GPCI), Medicare participation, and date of service. Reimbursement values are multiplied together along with the Relative Value Unit (RVU) and GPCI values to arrive at your reimbursement totals. The totals shown represent both Facility and Non-Facility reimbursement, and you can use whichever is appropriate. Reimbursement information can change by date.

Procedure

1. Perform a CPT/HCPCS code search.
2. Click the Reimbursement icon from the icon bar. The Reimbursement detail page opens.
3. In the Options section, select Pro.
4. Select a Reimbursement Date.
5. Select a GPCI.
6. Select a level of Medicare Participation.
7. Select a Fee Schedule State.
8. Click Submit. Results display below the Options section.

For DME/POS/PEN Reimbursement

When a code is reimbursed via a DME, POS, or PEN fee schedule, this code does no show the usual page for Professional reimbursement. This information includes payment value (national, or by your selected facility’s state) with and without appropriate modifiers. An example of a code paid at a national rate is B9000.

When viewing reimbursement information for your state, check to see which modifiers apply. Each state and modifier combination is shown on a new line. The reimbursement total is shown on the far right. A good code to example this is E0747.

If your state column shows the value "All" this means that the code is paid nationally.

Jurisdiction and Category values are also shown in the table. Below are their definitions:

Value	Definition
Jurisdiction
D	DMERC Jurisdiction
L	Local Part B Carrier Jurisdiction
J	Joint DMERC/Local Carrier Jurisdiction
Category
IN	Inexpensively/Routinely Purchased
FS	Frequently Serviced
CR	Capped Rental
OX	Oxygen & Oxygen Equipment
OS	Ostomy, Tracheostomy & Urologicals
SD	Surgical Dressings
PO	Prosthetics & Orthotics
SU	Supplies
TE	TENS

CPT and HCPCS CMS State Data

CMS State pricing benchmark (updated annually) includes the prices from Outpatient services charged to CMS by all the hospitals located in your state. This range of prices gives you a lower (25%), median (50%), and higher (75%) of all the prices charged that year. The state displayed is based on the hospital location. The CPT/HCPCS code had to exist two years ago; many times, soft coded pricing is not available.

National proprietary data from FinThrive clients in between 3-20 months old. Prices represent entire hospital charges based on the Best Practice Standard Code. These prices include items with no CPT/HCPCS codes (e.g. Surgery time, room rates, or non-coded supplies). Data displays on the Best Practice Standard Code screen in code detail.

Reimbursement with Modifiers TC and 26

Professional reimbursement for some procedures is divided into a technical component (indicated by modifier 26). Total RVU and reimbursement for the procedure is split between the two work areas.

Certain procedures (for example, 70498) are subject to a payment cap. The calculated fee schedule total is compared with the OPPS cap value published by CMS, and the lesser of these values is defined as the payment amount for that procedure.

View ASC reimbursement information about your code on your selected date-of-service. The wage index applied to the code’s ASC payment amount equals the wage adjusted payment for your selected facility. Codes new to the ASC payment system show a 2008 transition year payment amount, which is the base amount actually being paid for this procedure this year. Codes are phased in to the schedule using a transition period, with payments stepping through each of four transitional years before arriving at the fully implemented payment amount. Multiple procedure discounting was implemented to the ASC system in 2008; double-check the Multiple Procedures line to see if the procedure is subject to a multi-procedure discount.

Procedure

1. Perform a CPT/HCPCS code search.
2. Click the Reimbursement icon from the icon bar. The Reimbursement detail page opens.
3. In the Options section, select ASC.
4. Click Submit. Results display.

Addendum M associates HCPCS codes to Composite APCs For OPPS Reimbursement

Composite Ambulatory Payment Classifications (APCs) provide a single payment for a comprehensive diagnostic and/or treatment service that is defined, for the purposes of the APC, as a service that is typically reported with multiple HCPCS codes.

When HCPCS codes that meet the criteria for payment of the composite APC are billed on the same date of service, a single payment is made for all of the codes as a whole, rather than paying each code individually.

Composite APCS are assigned a status indicator of Q3 in Addendum M. Addendum M lists the individual HCPCS assigned to the composite APC.

When one of the HCPCS is reported separately, payment is based upon the status indicator assigned in Addendum B. For example, if a "with and without MRI" are reported together, on the same date of service, they are paid at the assigned Composite APC rate. If only the "with or without MRI" is reported individually on the claim the individual study is reported as a standalone study for reimbursement.

You can upload custom fee schedules containing reimbursement information for payors other than Medicare. Up to five custom fee schedules can be uploaded per facility. All users with access to the facility can view uploaded custom fee schedules for that facility.

Note: Uploading custom fee schedules is available for Knowledge Source and KnowledgeSource Professionalusers only.

File Requirements

You can load up to five .csv files with the following requirements:

• Only .CSV format is supported.
• A maximum of 10 columns are allowed.
• The first row in the .CSV file must represent headers for all columns in the file.
• The first column in the .CSV file should be a valid CPT/HCPCS code.
• You can provide custom names for the other columns in the file.

Upload a New Custom Fee Schedule

Procedure

Note: You can load up to five fee schedules.

1. Type a CPT/HCPCS code into Go to Code. The CPT Detail page opens.
2. Click the Reimbursement icon from the icon bar. The Reimbursement detail page opens.
3. Click Upload Custom Fee Schedule. The Upload Fee Schedule form displays.
4. Enter a title for your custom fee schedule into the Schedule Name field.
5. Click Browse to search for your .csv file.
6. Click Upload.
7. If the upload was successful, a message displays.  Click OK.
8. The custom fee schedule displays as a radial button on the Reimbursement detail page. The upload date displays next to the fee schedule. Hover over the fee schedule name to view the user who uploaded the file, as well as the date of upload.

Note: Other users who have access to the facility may need to log out and log back in again to see the uploaded custom fee schedule(s) for that facility.

9. Select the radial button for the custom fee schedule to search for code information within that fee schedule. If the code is found in the fee schedule, the line item displays on the Reimbursement detail page.

Note: Uploaded custom fee schedules are also available in Advanced Search > Codebase. When an advanced search is performed for a CPT/HCPCS code, the number of times the code appears in the fee schedule displays in parenthesis next to it. Click the fee schedule and the line item(s) for the code displays in the results panel.

Delete a Custom Fee Schedule

Procedure

1. Select the radial button for the custom fee schedule you want to delete.
2. Select a facility version if necessary.
3. Click Submit. The fee schedule displays.
4. Click Delete in the top right corner of the fee schedule. The fee schedule is removed from the Reimbursement Detail page.

The Wage Adjusted APC Payment is the National Payment rate times the wage adjustment setup in your facility information. The wage index is applied according to your selected facility and the date of service. The calculation used to arrive at the Wage Adjusted APC Payment is the CMS calculation as given below:

If you click on an APC number, a new tab opens to show you APC details, as well as a list of all other codes in the APC. For codes that have conditional APC assignments (status indicators Q1, Q2, and Q3), each possible assignment is indicated along with a brief note about assignment criteria.

The chart displaying National Charge Percentiles is based on the range of prices from the CMS Standard Analytical File for hospitals outpatient services. The prices are a distribution of all prices for a given procedure, not a calculated average.

In the following example, the 75th Percentile Price is $644.71, meaning that 75% of the hospital charges reported are less than $644.71 and 25% are greater. The 50th Percentile Price of $446.49 indicates the true median price of all pricing reported for this particular procedure.

Note: The SAF year and number of procedures used in the calculations displays in the heading; in this example, pricing percentiles are based on 3,882,115 procedures; the SAF 2009 file as a whole contains data for 504,922,627 procedures on 144,639,772 claims.

The Peer Pricing chart shows pricing as reported by each peer hospital from OPPS LDS (Hospital Outpatient Prospective Payment System Limited Data Set) claims. Again, the prices shown are a distribution of all occurrences of charges for that particular procedure. In this example, the 75th percentile price is $825.30. This indicates that 75% of this hospital’s procedures were priced less than $825.30. The 90th percentile price is $866.56 and 10% are equal to or above.

This chart takes into account not only price changes occurring during the year, but also price variances between multiple departments providing the same procedure. Anytime pricing percentiles cannot be calculated, the display will indicate "Insufficient Data" exists to be reported.

Managers set up peer hospitals within Knowledge Source by accessing the Setup menu and selecting Peer Hospitals from the drop-down. Critical Access Hospitals are not included in the OPPS LDS data set and will not display when searching for peer hospitals.

Peer Hospital Pricing from OPPS LDS claims is viewable for users with access. The hospitals on the list are chosen by those with a Knowledge Source Manager role in Setup. These hospitals can be competing local hospitals, national systems in your market, or different locations within your enterprise.

• Each row in the table shows the price distribution for that procedure and hospitals. If the hospital has charged less than 5 distinct prices, the entries will not all be different. If the chosen hospital did not perform a statistically meaningful count of the procedure show a status of Insufficient Data.
• Each line indicates one competitor and their procedure price map.
• Compare the columns to see if they are all the same. If they are all the same, then that location always charged the same price for a procedure.
• The columns that show different pricing indicates that different prices were charged for the same procedure in various departments or locations.
• Peer Hospital Pricing Information may be up to three years old.