The Medicare Outpatient Calculator computes the Medicare reimbursement based on actual claims or selected criteria.
Procedure
- To access the Outpatient Medicare Calculator page, select Go To > Government Payor Research > Medicare > Outpatient Calculator.
- Specify the selection criteria for the Medicare reimbursement calculation.
- In the Patient Identification section, enter the gender, Date of Birth, bill type, and discharge status.
Note: Gender and Date of Birth are required to determine whether there are gender or age edits (errors).
- In the Claim Statistics section, enter a service from date (accept the default date or change it) and enter at least one diagnosis code.
- The service from date populates all other date fields, which you can change.
- The diagnosis code is required for National Correct Coding Initiative (NCCI) edits.
- In the Line Item Entry section, enter at least one revenue code, unit and charge amount.
- The CPT/HCPC entry (if applicable) can effect the reimbursement calculation, but is not required to calculate a reimbursement.
- By law, the charge amount is required to reimburse under a fee schedule.
- Clicking Click here to add more line items, adds one additional empty line (up to 50 line items, in total).
Note: If you access this page from the Reimbursement Detail page, the reimbursement selection criteria for the selected outpatient appear. You can add additional line-item charges or change criteria in a “what if” scenario. The reimbursement calculation here has no effect on the repriced account but projects Medicare outpatient reimbursement based on new (or current) criteria.
- In the Patient Identification section, enter the gender, Date of Birth, bill type, and discharge status.
- Select the 7.1% Rural SCH Add-on check box to include the 7.1% Rural SCH Add-on payment to lines items with SI P, S, T, V, R, J1 and J2. The default for this check box is unchecked.
- Click Calculate OPPS. The results appear. For more information, refer to View the Medicare Outpatient Calculator Results.
Lines with $0 Billed Charges Ignored with APC Grouper
The OPPS logic ignores lines with Total charges - Non-covered charges = $0 so that the grouper assigns the payable SI to the correct line item.
Note: Please be advised if the calculator is used, you must manually remove the CPT/HCPC code for the applicable line with total non-covered charges.
Field Descriptions
The following table describes each of the fields on the Outpatient Medicare Calculator page.
|
Field |
Description |
|
Hospital Identification |
|
|
Acute Provider Number/NPI |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims
|
|
Patient Identification |
|
|
Patient Gender |
Patient gender
|
|
Date of Birth |
Patient birth date
|
|
Bill Type |
Bill type
|
|
Discharge Status |
Patient’s destination upon discharge (home, LTC, and so on) |
|
Claim Status |
|
|
Service From |
First date of service rendered to the patient. This is required information, and defaults to today’s date. Cannot be prior to Date of Birth. |
|
Service Through |
Ending date the service was performed; required information; defaults to today’s date. Cannot be prior to Service From date. |
|
Condition Codes |
Codes describing the patient’s condition
|
|
Covered Charges |
Amount of charges covered by Workers’ Compensation or Medicare
|
|
Diagnosis Codes |
ICD Diagnosis Codes
|
|
Line Item Entry |
|
|
Rev. Code |
Revenue code |
|
CPT/HCPC Code |
Associated CPT or HCPC codes and modifiers |
|
Service Date |
Date the service was rendered |
|
Units |
Number of units; required information; defaults to 1. |
|
Total Charges |
Total charges for the procedure/line item |
|
Pricing Options |
|
|
7.1% Rural SCH Add-On |
Option to include the 7.1% Rural SCH Add-on payment to lines items with SI P, S, T, V, R, J1 and J2. |