Medicare OP

The Medicare OP reimbursement tool contains two tabs that provide a total of three pricing methodologies for use with Medicare contracts and Managed Care contracts that are based on Medicare:

  • Hosp Tab – Contains the following pricing methodology:
    • Ambulatory Payment Classification (APC) Pricing
  • ASC Tab – Contains the following pricing methodologies:
    • Fee Schedule Pricing – Used for ASC pricing by fee schedule using the 2007 and earlier methodology
    • Ambulatory Surgery Center (ASC) Pricing – Used for ASC pricing using the 2008 and later methodology

    • Note: These three methodologies are mutually exclusive so that selecting one of the options disables the other two. To use more than one methodology, you must create a separate service type for each methodology used.

  • Clinics - Ambulance - Home Health Tab – Provides the ability to define reimbursement for the following Medicare services not included in OPPS and ASC. Typically, this tab is used to support managed care contracts based on Medicare.
    • RHC – Defines reimbursement terms related to rural health clinics.
    • FQHC – Defines reimbursement terms for Federally Qualified Health Centers (FQHC).
    • Ambulance – Defines reimbursement terms related to ambulance services.

    • Note: The ORF, CORF, CMHC, DMEPOS/PEN, and NDC Drugs tools are not currently supported, but will be added in a future release.

Note: The tools on the Clinics - Ambulance - DMEPOS/PEN - NDC tab can be used in conjunction with the Ambulatory Payment Classification (APC) methodology on the Hosp tab, but cannot be used with either methodology on the ASC tab.

  • For Medicare contracts, select one of the following check boxes and leave all other fields at their default settings:
    • Ambulatory Payment Classification (APC) Pricing (Hosp Tab)
    • Fee Schedule Pricing (ASC Tab)
    • Ambulatory Surgery Center (ASC) Pricing (ASC Tab)
  • For managed care contracts based on Medicare, you can modify individual elements within the pricing methodology.
  • If a contract reimburses according to Medicare, you must determine if it is referencing true hospital reimbursement or the physician fee schedule (also called RBRVS).
    • If the contract does reference RBRVS, then the Medicare reimbursement tool is not applicable. You must create a lookup table and reference it from the Lookup tool or Code tool. For more information on this process, refer to Lookup Tool vs. Code Tool.