The Medicare Outpatient Calculator Results page displays the Medicare Outpatient Calculator results.
Note: To enter the calculation criteria, refer to Use the Medicare Outpatient Calculator
Procedure
- Access the Medicare Outpatient Calculator Results page.
- Select Go To > Medicare Research > Outpatient Calculator. The Outpatient Medicare Calculator opens.
Alternatively, access an outpatient account in Account Research, drill down to the Expected Reimbursement Detail page and click Calculate Reimb. as OPPS (a link at the top of the page).
- Specify the calculation criteria and click Calculate Reimbursement. The calculation results appear.
- Select Go To > Medicare Research > Outpatient Calculator. The Outpatient Medicare Calculator opens.
- View the calculation results.
- To view additional details regarding the information on this page:
- Click the Bill Type link to display the Billing Type Definition page. For more information, refer to Billing Type Definition.
- In the Payment Status and Error Code columns, place your cursor over a code to display an explanation of the code.
- In addition, status and error codes are explained in separate tables beneath the outpatient calculator results.
- If you started your calculation with a repriced claim, only codes on the selected claim are explained.
- To change your selection criteria.
- Click New OPPS Calculator to display the default, mostly empty selection criteria (blank revenue codes, units and charges).
- Click Recalculate MCR OPPS to display the most current selection criteria, which you can modify.
Field Description
The following table describes each of the fields on the Outpatient Medicare Calculator page.
|
Field |
Description |
|
Acute NPI |
Facility’s ten-digit National Provider Identification (NPI) number required on all claims |
|
Patient Gender |
Patient gender |
|
Patient DOB |
Patient birth date |
|
Bill type |
|
|
Patient’s destination upon discharge (home, LTC, and so on) |
|
|
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 |
|
Diagnosis Codes |
ICD Diagnosis Codes |
|
Claim Error |
Error code for the claim level |
|
Claim Disposition |
Disposition code for claim level |
|
Reimbursement Type |
Reimbursement type, either expected reimbursement or RA, if applicable (the latest RA is shown if there are multiple RAs) |
|
APC Payment, Excluding Outliers |
Reimbursement from the APC, a set of payment rates based on groups of outpatient services rather than on individual services |
|
New Tech Pass-through Payment |
Reimbursement for certain high-cost items like implants, high cost drugs and biologicals, for which the actual or higher cost is passed through to the payor |
|
Fee Schedule Payment/Composite Rate Payment |
Reimbursement from a fee schedule (Lab, DMEPOS, PEN, and therapies) |
|
Total Claim Outlier Payment |
Amount for extraordinarily high cost (cost outlier) |
|
Total Payments/PPS Payment (Including Outliers) |
Expected amount from Medicare |
|
Total Medicare Payment |
Total Medicare payment |
|
Total Patient Responsibility |
Patient’s copay |
|
No. |
Sequential number of the account in the current set of accounts, based on the sort method |
|
Line Item Date of Service (LIDOS) |
Date the service was rendered |
|
Revenue code |
|
|
Associated CPT or HCPC codes and modifiers |
|
|
APC Codes |
Ambulatory Payment Classification codes |
|
APC Weight |
The Ambulatory Payment Classification (APC) weight applied to the line item |
|
Payment Status Codes |
APC payment status codes |
|
Billed Units |
Number of units billed |
|
Charges |
Charged amount |
|
Expected Base Payment |
Total expected payment for the line |
|
Outlier Amount APC, only |
APC amount for extraordinarily high cost |
|
Patient Co-Pay |
The co-payment amount. |
|
IP Deductible Capped Amount |
The inpatient deductible capped amount. |
|
Total APC Payment |
Reimbursement from the APC, a set of payment rates based on groups of outpatient services rather than on individual services |
|
Message & Error Codes |
Reason for rejection or return, if applicable |
|
Payment Status Code Definitions |
Definitions of Payment Status Codes listed |