Provider Summary of Outpatient Prospective Payment System APC 2016

$179 / year

This dataset contains estimated hospital specific charges for 35 Ambulatory Payment Classification (APC) Groups paid under the Medicare Outpatient Prospective Payment System (OPPS) for Calendar Year (CY) 2016. 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

2016-06-15

Last Modified

2019-08-28

Version

2019-08-28

Update Frequency

Annual

Temporal Coverage

2015

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare & Medicaid Services;

Source License URL

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 2016, Medicare Suffix for OPPS Provider Summary 2016, Medicare Doctors Provider Summary for OPPS 2016

NameDescriptionTypeConstraints
Ambulatory_Payment_Classification_NumberAPCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. It represents the numeric part of the APC group code.string-
Ambulatory_Payment_Classification_GroupAPCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. It represents the specific group for the APC.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.integerlevel : Nominal required : 1
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
State_AbbreviationTwo-letter state abbreviation in the mailing address of the hospital. This includes information on hospitals in:stringrequired : 1
Zip_Code5 digit postal zip code in the mailing address of the hospital.integerlevel : Nominal required : 1
Provider_Hospital_Referral_Region_DescriptionDescribes the hospital referral region of the provider.stringrequired : 1
BeneficiariesThe number of Medicare fee-for-service beneficiaries receiving outpatient hospital services.string-
Outpatient_ServicesThe number of outpatient services provided.integerlevel : Interval required : 1
Average_Estimated_Submitted_Charges_In_DollarsIndicates the average estimated charges in US Dollars submitted to Medicare by a facility or provider.numberlevel : Ratio required : 1
Average_Total_Payments_In_DollarsIndicates the average estimated total payments in US Dollars.numberlevel : Ratio required : 1
Average_Medicare_Payment_AmountThe average of total regular payments the provider receives directly from Medicare. It excludes special outlier payments which is reported in a separate column.numberlevel : Ratio required : 1
Outlier_Comprehensive_APC_ServicesThe number of comprehensive APC services with outlier payments.numberlevel : Ratio
Average_Medicare_Outlier_AmountThe average of outlier payments the provider receives directly from Medicare. OPPS APC payment amounts are based on the average costs for a set of services. In the event that a hospital’s costs for these services exceed a given threshold tied to the average APC payment, CMS must issue an outlier payment to the hospital to that service to compensate for the costly provision of service.numberlevel : Ratio
Ambulatory Payment Classification NumberAmbulatory Payment Classification GroupProvider IdProvider NameProvider Street AddressProvider CityState AbbreviationZip CodeProvider Hospital Referral Region DescriptionBeneficiariesOutpatient ServicesAverage Estimated Submitted Charges In DollarsAverage Total Payments In DollarsAverage Medicare Payment AmountOutlier Comprehensive APC ServicesAverage Medicare Outlier Amount
5123Level 3 Musculoskeletal Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan15916119543.723977.093168.730.00.0
5124Level 4 Musculoskeletal Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan495022645.595652.534503.640.00.0
5125Level 5 Musculoskeletal Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan383927823.48425.197137.190.00.0
5165Level 5 ENT Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan202013315.053166.732523.080.00.0
5191Level 1 Endovascular Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan12517531421.763673.992927.2525.0741.64
5192Level 2 Endovascular Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan31835352533.387631.016341.91
5193Level 3 Endovascular Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan11311878801.8511671.5810383.48
5222Level 2 Pacemaker and Similar Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan919231986.745357.84267.380.00.0
5223Level 3 Pacemaker and Similar Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan13813851309.487415.376127.370.00.0
5231Level 1 ICD and Similar Procedures10001Southeast Alabama Medical Center1108 Ross Clark CircleDothanAL36301AL - Dothan232375148.4317516.9816228.980.00.0