Medicare's Outpatient Prospective Payment System: Calculating APC Payments

Course Code: REL-RCC-OPPS-C04

Hours: 0.5

Type: Online Course

Content Expiration Date: 12/31/2028

Learning Objectives:
Apply computations for provider-specific APC payment rates.
Recall how geographic location affects adjustments.
Determine when APC payments are subject to discounting.
Recall deductible amounts for Medicare Part B.
Correctly calculate coinsurance amounts.
Recall pass-through payments for drugs.
Recognize the impact modifiers -52, -73, and -74 have on APC reimbursement.

Outline:

Section 1: Introduction

About This Course

Learning Objectives

APC Payment Groups

Section 2: Rates

Determining APCs and APC Rates: Addendum A

Determining APCs and APC Rates: Addendum B

Determining APCs and APC Rates: Addendum M

Calculation of APC Rates and Weights

Review

Section 3: Calculations

Establishing the OPPS Conversion Factor

Rates Calculated from Weights

Use of Modifiers for Discontinued Services

Discounting

Review

Calculating Hospital-Specific Payments

Payment Rate Calculation

Example of Hospital Payment

Review

Section 4: Payments

OPPS Coinsurance

Deductible

Calculating Payments with Deductibles and Coinsurance

Outlier Payments

Sample Outlier Payment Calculation

Review

Section 5: Conclusion

Course Summary

Course Contributors

Resources

References

Reviewer: Brandi D. Burgett, CCS, CPC

Brandi has over twenty-five years of medical billing and coding experience. Her areas of expertise include beginning-to-end revenue cycle operations, hands-on coding for multiple outpatient specialties, and medical record auditing. Prior to medical coding, Brandi was a Team Lead for a large team of pediatric specialty providers in Virginia.

Target Audience:
The target audience for this course is: Healthcare Billing and Coding; in the following settings: Hospitals: Acute.

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To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.