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Serving Wyoming EqualityCare Providers



OPPS Information



Outpatient Prospective Payment System (OPPS) Project

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 HealthCare Financing

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.

Update Notice

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 hospitals).
  • 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 policies.

Changes in Reporting for Outpatient Visits

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 68,677-68,680]