Outpatient Prospective Payment System OPPSCAP

$79 / year

This Outpatient Prospective Payment System (OPPSCAP) dataset contains the payment amounts after the application of the OPPS based payment caps, except for carrier priced codes. For carrier priced codes, the field only contains the OPPS based payment caps. Carrier prices, however, cannot exceed the OPPS based payment caps.

Complexity

This dataset shows Section 5102(b) of the Deficit Reduction Act of 2005 that requires a payment cap on the technical component (TC) of certain diagnostic imaging procedures and the TC portions of the global diagnostic imaging services. This cap is based on the Outpatient Prospective Payment System (OPPS) payment. To implement this provision, the physician fee schedule amount is compared to the OPPS payment amount and the lower amount is used in the formula below to calculate payment.

2018 OPPS Non-Facility Payment Amount =
[(Work RVU * Work GPCI) + (OPPS Non-Facility PE RVU * PE GPCI) +
(OPPS MP RVU * MP GPCI)] * Conversion Factor

2018 OPPS Facility Payment Amount =
[Work RVU * Work GPCI) + (OPPS Facility PE RVU * PE GPCI) +
(OPPS MP RVU * MP GPCI)] * Conversion Factor

Date Created

2015-05-28

Last Modified

2017-12-20

Version

2017-12-20

Update Frequency

Quarterly

Temporal Coverage

2017-07 to 2018-05

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

CMS Fee Schedule, Medicare Fee Schedule 2018, Medicare Fee Schedule 2017, Medicare Physician Fee Schedule, Medicare Rate 2018, Medicare Rate 2017, OPPSCAP 2018, OPPSCAP 2017, OPPS Based Payment Caps, Outpatient Prospective Payment System 2018, Outpatient Prospective Payment System 2017

Other Titles

OPPS Based Payment Caps 2018, OPPS Based Payment Caps 2017, PROCSTAT for Outpatient Prospective Payment System 2018, PROCSTAT for Outpatient Prospective Payment System 2017

NameDescriptionTypeConstraints
YearYear for Outpatient Prospective Payment System OPPSCAP (2017 and 2018)date-
HCPCSCPT or Level 2 HCPCS number for the service.string-
Procedure_Status_CodeThis column includes the Procedure Status Code. If, ‘A’ is listed in this column and indicates an Active Code, which means the code is paid if covered. R: Payment is restricted, although Medicare may reimburse for the service/procedure in some circumstances. These services are carrier-priced.C: The listed procedure or service is carrier priced. Although some carriers may choose to establish a fee schedule amount for some such codes, in most cases they will not. Therefore, the effective payment for “C” status codes is usually zero.string-
Carrier_CodeCarrier Code used for Healthcare Common Procedure Coding System (HCPCS)integerlevel : Nominal
Locality_CodeLocality Code used for Healthcare Common Procedure Coding System (HCPCS)string-
Facility_PriceThis column includes the fee schedule amount when a physician performs a procedure in a non-facility setting such as the office. (Non-facility fees are applicable to therapy procedures regardless of whether they are furnished in facility or non-facility settings.)numberlevel : Nominal
NonFacility_PriceThis column includes the fee schedule amount when a physician performs a procedure in a non-facility setting such as the office. (Non-facility fees are applicable to therapy procedures regardless of whether they are furnished in facility or non-facility settings.)numberlevel : Nominal
YearHCPCSProcedure_Status_CodeCarrier_CodeLocality_CodeFacility_PriceNonFacility_Price
201775571A111258181
201776120A530227777
201776120A620208080
201776120A111258181
201776380A111258181
201776496C111258181
201776497C111258181
201776498C111258181
201776800A111258181
201776885A111258181