CMS Pub. 100-04, ch. 4, § 50.6

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

effective beginning January 1, 2003.

A. New OPPS wage indexes will be effective January 1, 2003. These are the same wage

indexes that were implemented on October 1, 2002, for inpatient hospitals. Some

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

using the corrected wage indexes where applicable.

B. Inpatient hospitals considered reclassified on October 1, 2002, will be considered

reclassified for OPPS on January 1, 2003.

C. Section 301 designations and floor MSA designations will be considered effective for

OPPS on January 1, 2003.

D. New payment rates and coinsurance amounts will be effective for OPPS on January 1,

2003. Some APCs have coinsurance amounts limited to 55 percent of the payment

rate effective January 1, 2003. Some APCs have a coinsurance limit equal to the

inpatient deductible of $840 effective January 1, 2003.

E. If a claim has more than 1 service with a status indicator (SI) of T (SI of S has been

removed from this rule) and any lines with SI T have less than $1.01 as charges,

charges for all T lines will be summed and the charges will then be divided up

proportionately to the payment rate for each 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

T $19,999 $6,000 $12,000

T $1 $3,000 $ 6,000

T $0 $1,000 $ 2,000

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

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

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

F. For outliers, CMS will change the factor multiplied times the total line item payments

from 3.5 to 2.75 and the factor used to multiply the difference between line item

payments and costs from .50 to .45. The CMS will eliminate the cost to charge ratio

adjustment factor of .981956 from outlier and device calculations.

G. Any claim having one or more APCs that match those listed in the Device Offset

Table (Table 11) published in the November 1, 2002, “Federal Register” and a

HCPCS code with status indicator (SI) H, will have all applicable APC offset

amounts (multiplied by the number of units and the multiple procedure discount

factor applicable to that line item) summed and wage adjusted. If there are more units

of APCs with offset amounts than there are units of SI H devices that have an active

(non-deleted) device category HCPCS code beginning with a C, i.e., those codes

listed in section XXII B. of this PM, the total wage adjusted offset amount will be

multiplied by the number of units of SI H devices that have a HCPCS code beginning

with a C and then divided by the number of units of APCs with offset amounts. The

total wage adjusted offset amount will then be subtracted proportionately from the

charges reduced to costs for any SI H devices that have a HCPCS code beginning

with a C.

The pro rata reduction of 63.6 percent applicable to all SI G and/or H payments is

eliminated.