Use the Medicare Outpatient Calculator

The Medicare Outpatient Calculator computes the Medicare reimbursement based on actual claims or selected criteria.

  1. To access the Outpatient Medicare Calculator page, select Go To > Government Payor Research > Medicare > Outpatient Calculator.
  2. Specify the selection criteria for the Medicare reimbursement calculation.
    1. 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).

    2. 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.
    3. 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.

  3. 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.
  4. Click Calculate OPPS. The results appear. For more information, refer to View the Medicare Outpatient Calculator Results.

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.

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.