Provider Summary of Outpatient Prospective Payment System APC 2012

$79 / year

This dataset contains estimated hospital specific charges for 30 Ambulatory Payment Classification (APC) Groups paid under the Medicare Outpatient Prospective Payment System (OPPS) for Calendar Year (CY) 2012. The Medicare payment amount includes the APC payment amount, the beneficiary Part B coinsurance amount and the beneficiary deductible amount.

Complexity

In response to the rapidly growing Medicare expenditures for outpatient services and large co-payments being made by Medicare beneficiaries, Congress mandated that the Centers for Medicare and Medicaid Services (CMS) develop a Hospital Outpatient Prospective Payment System (HOPPS) and reduce beneficiary co-payments. This payment system, implemented August 1, 2000, is used by CMS to reimburse for hospital outpatient services.

The hospital outpatient prospective payment system (OPPS) in place today classifies all hospital outpatient services into Ambulatory Payment Classifications (APCs). Ambulatory Payment Classifications (APCs) are CMS’ grouping system developed for facility reimbursement for hospital outpatient services. All covered outpatient services to an APC group. Each group of procedure (i.e.,codes) within an APC is supposed to be “similar clinically and with regard to resource consumption.” Healthcare Common Procedure Coding System codes (HCPCS codes) are assigned to APCs by CMS, and these assignments are updated at least annually (HCPCS code sets include the full Current Procedural Terminology code set).

The services assigned to any APC are considered by CMS to be clinically similar and similar in terms of the resources required to provide each service. Thus, one APC may be applied to numerous HCPCS codes, whereas any individual HCPCS code can be assigned to only one APC. Notably, many HCPCS codes are not assigned to any APC. Some are considered “packaged” into some other code, some are identified as appropriate only for the inpatient setting, and some are simply not considered by CMS to be payable under the OPPS. Thus, one must actually refer to the CMS files listing all HCPCS codes in order to determine whether the service is paid.

Date Created

2014-05-29

Last Modified

2017-03-30

Version

2017-03-30

Update Frequency

Annual

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare & Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Outpatient Prospective Payment System, Ambulatory Payment Classification Groups, Medicare Hospital, Hospital Service Areas (HSAs)

Other Titles

Medicare Home Healthcare Outpatient Prospective Payment System 2012, Medicare Suffix for OPPS Provider Summary 2012, Medicare Doctors Provider Summary for OPPS 2012

Name Description Type Constraints
Ambulatory_Payment_ClassificationAPCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program.stringrequired : 1
Provider_IdCenters for Medicare & Medicaid Services (CMS) certification number (CCN). Identification number of the facility within the CMS dataset. The CCN for providers and suppliers is a 6 digit number. The first 2 digits identify the State in which the provider is located.The last 4 digits identify the type of facility.integerrequired : 1 level : Nominal
Provider_NameName of the hospital (also referred to as the provider)stringrequired : 1
Provider_Street_AddressMain street address information of the hospitalstringrequired : 1
Provider_CityMailing city. The city in the main street address of the hospital.stringrequired : 1
Provider_StateTwo-letter state abbreviation in the mailing address of the hospital. This includes information on hospitals in:stringrequired : 1
Provider_Zip_Code5 digit postal zip code in the mailing address of the hospital.integerrequired : 1 level : Nominal
Provider_Hospital_Referral_Region_DescriptionDescribes the hospital referral region of the provider.stringrequired : 1
Outpatient_ServicesThe number of outpatient services provided.integerrequired : 1 level : Interval
Average_Estimated_Submitted_Charges_In_DollarsIndicates the average estimated charges in US Dollars submitted to Medicare by a facility or provider.numberrequired : 1 level : Ratio
Average_Total_Payments_In_DollarsIndicates the average estimated total payments in US Dollars.numberrequired : 1 level : Ratio
Ambulatory_Payment_Classification_NumberAmbulatory_Payment_Classification_GroupProvider_IdProvider_NameProvider_Street_AddressProvider_CityState_AbbreviationZip_CodeProvider_Hospital_Referral_Region_DescriptionOutpatient_ServicesAverage_Estimated_Submitted_Charges_In_DollarsAverage_Total_Payments_In_Dollars
0368 Level II Pulmonary Tests390063UPMC HAMOT201 STATE STREETERIEPA16550PA - Erie174200.5956.45
0206 Level II Nerve Injections390063UPMC HAMOT201 STATE STREETERIEPA16550PA - Erie151286.2220.87
0377 Level II Cardiac Imaging390063UPMC HAMOT201 STATE STREETERIEPA16550PA - Erie6894626.27600.96
0368 Level II Pulmonary Tests360010UNION HOSPITAL659 BOULEVARDDOVEROH44622OH - Canton132132.4957.2
0368 Level II Pulmonary Tests450678DOCTORS HOSPITAL9440 POPPY DRDALLASTX75218TX - Dallas15320.4261
0019 Level I Excision/ Biopsy360010UNION HOSPITAL659 BOULEVARDDOVEROH44622OH - Canton11667.62250.68
0078 Level III Pulmonary Treatment390063UPMC HAMOT201 STATE STREETERIEPA16550PA - Erie90970.7887.96
0204 Level I Nerve Injections360010UNION HOSPITAL659 BOULEVARDDOVEROH44622OH - Canton86383.17157.19
0368 Level II Pulmonary Tests520089MERITER HSPTL202 S PARK STMADISONWI53715WI - Madison17507.2366.58
0019 Level I Excision/ Biopsy520089MERITER HSPTL202 S PARK STMADISONWI53715WI - Madison26617.45318.08