Hospital Outpatient PPS (Test 4)
HOPPS - answer Hospital Outpatient Prospective Payment System
Balanced Budget Act (BBA) of 1997 set implementation date for HOPPS, which was
implemented by... - answer CMS on August 1, 2000
Prior to HOPPS, Medicare payment for hospital outpatient services was based on cost -
answer Cost of Services = Total Charges X Department Specific CCR (cost-to-charge
ratio) developed from cost report statistics
HOPPS uses 3 reimbursement methods: - answer1- Fee schedules
2- Prospective Payment
3- Cost-Based
Fee schedules - - answer a separate payment amount for each item or service with no
packaging
Examples - Ambulance transportation, PT, OT and ST services, Laboratory services
Physician and nonphysician practitioners are paid under the Resource-Based Relative
Value Scale (RBRVS), the Medicare Physician Fee Schedule (MPFS)
Prospective Payment - - answerthe cost for certain items and secondary services
associated with the primary procedure are packaged into the payment for that
procedure
~Most outpatient procedures and services are reimbursed under the APC (Ambulatory
Payment Classification) System
~End-Stage Renal Disease (ESRD) services are reimbursed under their own PPS
Cost-Based - - answerBased on reasonable cost to provide services
Examples - Acquisition of corneal tissue, influenza and pneumococcal pneumonia
vaccines
Facilities are required to use HCPCS Level I (CPT) and Level II codes to report
services/ procedures and items/supplies provided to beneficiaries - answer~Each
HCPCS code (Level I and II) has been assigned a Payment Status Indicator (SI) Code
, ~This code establishes how that service, procedure, or item is paid (e.g., fee schedule,
APC, reasonable cost or not paid)
~There are multiple status indicator codes assigned per claim
HOPPS covers only outpatient services - answer~Annually, the Secretary of Health &
Human Services develops the "Inpatient Only List"
~These procedure codes will be assigned a payment status indicator "C" which
indicates Inpatient only services and therefore will not be reimbursed under the HOPPS
~To move off of the inpatient-only list, a procedure must be performed in the outpatient
setting at least 60% of the time
~To be reimbursed, "inpatient only procedures" must be provided to Medicare
beneficiaries in an inpatient setting and will then be reimbursed under the IPPS (DRGs)
Facilities Excluded from the HOPPS: - answer~Hospitals providing only Part B services
to inpatients
~Hospitals in Maryland and those paid under Maryland All-Payer Model
~Critical Access Hospitals (CAHs)
Facilities Excluded from the HOPPS - Continued - answer~Hospitals located in
American Samoa, Guam, the Commonwealth of the Northern Mariana Islands and the
Virgin Islands
~Indian Health Services (IHS) and Tribal Hospitals, including IHS Tribal CAHs
Maintenance of HOPPS - answer~CMS is responsible for the policy and maintenance of
the HOPPS
~Annual review of the APC groups, relative weights, payment rates and geographic
wage index
~Payment amounts adjusted annually based on the market-basket percentage
(inflation), multifactor productivity (MFP), and any other mandated adjustments for the
calendar year (CY)
~APC Advisory Panel assists with the maintenance of HOPPS by providing advice for
enhancement and modifications to the system
APC Advisory Panel: - answer~Comprised of 15 healthcare industry experts
HOPPS - answer Hospital Outpatient Prospective Payment System
Balanced Budget Act (BBA) of 1997 set implementation date for HOPPS, which was
implemented by... - answer CMS on August 1, 2000
Prior to HOPPS, Medicare payment for hospital outpatient services was based on cost -
answer Cost of Services = Total Charges X Department Specific CCR (cost-to-charge
ratio) developed from cost report statistics
HOPPS uses 3 reimbursement methods: - answer1- Fee schedules
2- Prospective Payment
3- Cost-Based
Fee schedules - - answer a separate payment amount for each item or service with no
packaging
Examples - Ambulance transportation, PT, OT and ST services, Laboratory services
Physician and nonphysician practitioners are paid under the Resource-Based Relative
Value Scale (RBRVS), the Medicare Physician Fee Schedule (MPFS)
Prospective Payment - - answerthe cost for certain items and secondary services
associated with the primary procedure are packaged into the payment for that
procedure
~Most outpatient procedures and services are reimbursed under the APC (Ambulatory
Payment Classification) System
~End-Stage Renal Disease (ESRD) services are reimbursed under their own PPS
Cost-Based - - answerBased on reasonable cost to provide services
Examples - Acquisition of corneal tissue, influenza and pneumococcal pneumonia
vaccines
Facilities are required to use HCPCS Level I (CPT) and Level II codes to report
services/ procedures and items/supplies provided to beneficiaries - answer~Each
HCPCS code (Level I and II) has been assigned a Payment Status Indicator (SI) Code
, ~This code establishes how that service, procedure, or item is paid (e.g., fee schedule,
APC, reasonable cost or not paid)
~There are multiple status indicator codes assigned per claim
HOPPS covers only outpatient services - answer~Annually, the Secretary of Health &
Human Services develops the "Inpatient Only List"
~These procedure codes will be assigned a payment status indicator "C" which
indicates Inpatient only services and therefore will not be reimbursed under the HOPPS
~To move off of the inpatient-only list, a procedure must be performed in the outpatient
setting at least 60% of the time
~To be reimbursed, "inpatient only procedures" must be provided to Medicare
beneficiaries in an inpatient setting and will then be reimbursed under the IPPS (DRGs)
Facilities Excluded from the HOPPS: - answer~Hospitals providing only Part B services
to inpatients
~Hospitals in Maryland and those paid under Maryland All-Payer Model
~Critical Access Hospitals (CAHs)
Facilities Excluded from the HOPPS - Continued - answer~Hospitals located in
American Samoa, Guam, the Commonwealth of the Northern Mariana Islands and the
Virgin Islands
~Indian Health Services (IHS) and Tribal Hospitals, including IHS Tribal CAHs
Maintenance of HOPPS - answer~CMS is responsible for the policy and maintenance of
the HOPPS
~Annual review of the APC groups, relative weights, payment rates and geographic
wage index
~Payment amounts adjusted annually based on the market-basket percentage
(inflation), multifactor productivity (MFP), and any other mandated adjustments for the
calendar year (CY)
~APC Advisory Panel assists with the maintenance of HOPPS by providing advice for
enhancement and modifications to the system
APC Advisory Panel: - answer~Comprised of 15 healthcare industry experts
