CMS Pub. 100-04, ch. 4, § 50.4

The following list contains a description of all OPPS Pricer logic changes that are

effective beginning April 1, 2002.

A. New OPPS wage indexes will be effective April 1, 2002. These are the same wage

indexes that were implemented on October 1, 2001, for inpatient hospitals. Some

corrections have been made since the publication of the inpatient rule, and CMS is

using the corrected wage indexes where applicable.

B. Inpatient hospitals considered reclassified on October 1, 2001, will be considered

reclassified for OPPS on April 1, 2002.

C. Section 401 designations and floor MSA designations will be considered effective for

OPPS on April 1, 2002.

D. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002,

except those 55 APCs with coinsurance amounts limited to 55 percent of the payment

rate, which were effective January 1, 2002. The coinsurance limit equal to the inpatient

deductible of $812 remains effective January 1, 2002.

E. APC 339, for Observation, will be priced at 1 unit no matter how many units are

submitted.

F. If a claim has more than 1 service with a status indicator (SI) of S or T and any lines

with SI of S or T have less than $1.01 as charges, charges for all S and/or T lines will

be summed and the charges will then be divided up proportionately to the payment rate

for each S or T line. The new charge amount will be used in place of the submitted

charge amount in the line item outlier calculation.

EXAMPLE:

SI Charges Payment Rate New Charges Amount

S $19,999 $6,000 $12,000

SI Charges Payment Rate New Charges Amount

T $1 $3,000 $6,000

S $0 $1,000 $2,000

$20,000 $10,000 $20,000

Because total charges here are $20,000 and the first SI of S gets 6,000 of 10,000 total

payment, the new charge for that line is 6,000/10,000 * $20,000 = $12,000.

G. All charges on lines with a SI of N (bundled services) on the claim will be summed and

the charges will then be divided up proportionately to the payment rate for each S, T,

V or X line. This proportional amount will be added to the new charges amount from

item F above or, if that doesn't apply, they will be added to the actual submitted charges

for each S, T, V or X before making a line item outlier calculation.

H. Outliers will be calculated at a line item level. No outlier payment will be calculated

for SIs of G, K, N or H, although charges for packaged services (SI=N) will be used in

calculating outlier payments for other services as described in G. above. Price r will

use submitted charges as modified by items F and G above. The CMS changed the

factor multiplied times the total claim payments from 2.5 to 3.5 and factor used to

multiply the difference between claim payments and costs from .75 to .50. Pricer will

keep the cost to charge ratio adjustment factor at .981956. Pricer will sum all line item

outlier amounts and output them as a single total claim outlier amount, just as it outputs

the outlier amount that contractors are to place in value code 17.

I. Any claim with one or more APCs that match those listed in Table 1 of the March 1,

2002, “Federal Register” will have all applicable APC offset amounts summed and

wage adjusted. The total wage adjusted offset amount will be subtracted

proportionately from the charges reduced to costs for any SI H devices that have a

HCPCS code beginning with a C, i.e., C1713 through C2631.

J. A pro rata reduction of 63.6 percent applies to all SI G and/or H payments. For H,

devices, the offset (or reduction) is applied to the final payment amount after all

device offset amounts (see item I above) have been taken. For SI G, pass thru drugs,

CMS determines the pass-through amount (PTA) by subtracting 5 times the minimum

coinsurance from the Medicare payment amount. The CMS will multiply .364 times

the PTA and add that amount to 5 times the minimum coinsurance to get the new

Medicare payment amount.

K. The provider specific file for SNFs and HHAs that may be reimbursed for splints,

casts and/or antigens under OPPS should have a cost to charge ratio of 0.000 (or

0.001 if the shared system will not allow 0.000. Pricer will not pay outliers for these

services.

L. Pricer Drug Copayment Changes

M. APC N. Drug Name O. Corrected Copayment

P. 726 Q. Dexrazoxane R. $27.85

S. 1607 T. Eptifibatide U. $1.62