Outpatient Prospective Payment System (OPPS)
Effective October 1, 2005, the Wyoming
Department of Health, Office of Health Care Financing
EqualityCare implemented a Medicare-based outpatient
hospital reimbursement methodology, using the Outpatient Code
Editor with Ambulatory Payment Classification (OCE/APC)
system. This document provides a description of the new
methodology, which is subject to change. This system has
recently changed to the Integrated Outpatient Code Editor
(IOCE) effective July 1, 2007 to be inclusive of OPPS and
Non-OPPS processing if so necessary.
Implementation of IOCE Software for the Office of
CMS sends software, transmittals, direction etc. for system
changes and updates out to State Medicaid offices once CMS has
it finalized. Wyoming EqualityCare bases a good portion
of OPPS decisions on Medicare rules and guidelines and because
of this is dependent upon receiving the data from Medicare
necessary to make changes to OPPS. Providers have voiced
concern about new codes implemented with CMS and not Wyoming
EqualityCare. Our office will need to implement one
quarter behind Medicare to allow time for systems changes.
For the 2010 updates, Wyoming EqualityCare will make
specific, targeted updates to the OPPS systems that are
different from those in past quarters. Effective January
1, 2011, Wyoming EqualityCare will:
- Implement the IOCE for outpatient hospital claims
processing each quarter.
- Annually implement adjusted OPPS conversion
factors for the three hospital types (general
hospitals, critical access hospitals and children's
- Implement new procedure codes with the current year's
status indicators and relative weights.
- Delete procedure codes that Medicare deletes.
In addition, Wyoming EqualityCare will continue to
implement the quarterly changes one quarter after the
information is received from CMS. However, to address
providers' concerns regarding the implementation and effective
date of procedure codes, quarterly updates will
have the same effective date for Equality Care as for Medicare
(e.g., EqualityCare will implement Medicare's January updates
on April 1 with an effective date of January
1). Therefore, to be paid in accordance with
the most recent quarterly update, providers must
resubmit/adjust (as applicable) their outpatient hospital
claims after EqualityCare's implementation
date. EqualityCare will not retroactively adjust
outpatient hospital claims upon implementation of the
quarterly changes. For example, a claim with a date of service
of January 10, 2011 submitted for payment on January 20, 2011
would initially be paid under the October
2010 EqualityCare payment policy (since that would
be in effect on January 20); after April 1, 2011, the provider
could resubmit, or adjust (as appropriate) the claim for
corrected payment and EqualityCare would reprocess the claim
to be paid under the January 2011 EqualityCare payment
Changes in Reporting for Outpatient
Medicare has modified the definition of new and established
patients for reporting hospital outpatient visits under OPPS.
Beginning in CY 2009, an established patient is based on
whether the patient has been registered as an inpatient
or outpatient of the hospital within the past 3 years.
Previously, established patients were those who had a
hospital medical record number assigned within the last 3
years, which was more difficult for hospitals to identify.
Medicare calculates the relative weight for each procedure
code based on historical claims costs and charges. Since
Wyoming Medicaid adopts Medicares relative weights, Wyoming
Medicaid providers should bill according to Medicare
definitions to be paid appropriately under OPPS.
[Source: Federal Register, Volume 73, No. 223, pages