美國保險/給付彙整筆記

medicare part a: hospital service [1]

medicare part b: medical insurance and covers expenses (set rates)[2]

OPPS: Outpatient Prospective Payment System

->醫療機構跟medicare, insurance companies請款方式/系統， OPPS底下有三種報銷(reimbursed)對照表：1. APCs 2.Fee schedule 3. reasonable cost

OPPS Payment Status Indicators: are assigned to every CPT/HCPCS (Level 1: CPT code, Level 2: CMS)code and the indicators identify if the code is paid under OPPS and if it is a separate or packaged code.[3]

->OPPS指示，告訴coder是不是用OPPS請款,或是看請款是獨立或是整包的碼(separate or packaged code) e.g., a, g, j1

A: No paid under OPPS

G: 在opps底下，是獨立的apc payment

Paid under OPPS, 用comprehensive APCs

APCs: are the main unit of payment under the OPPS.

-> 請款的對照表(set rates)，是medicare依照HCPCs code對應給healthcare provider看的單位(我的理解：對應表)，outpatient centers, ASCs幾乎所有的procedure都是對照APCs跟medicare, insurance companies報銷。

OPPS 內對應的APCs (P.7)

comprehensive APCs(C-APCs): A classification for the provision of a primary service and all adjunctive services provided to support the delivery of the primary service

• >2015前的APC是手術中的每項component單獨報銷，C-APCs把手術夯不啷噹東西算成一整包服務的意思，常常會有下列的報銷項目[4]：

● All supplies
● Ancillary services
● Anesthesia
● Operating and recovery room use
● Clinical diagnostic laboratory tests
● Procedures described by add-on codes
● Implantable medical devices, such as pacemakers
● Inexpensive drugs under a per-day drug threshold packaging amount
● Drugs, biologicals, and radiopharmaceuticals functioning as supplies, including diagnostic radiopharmaceuticals, contrast agents, stress agents, implantable biologicals, and skin substitutes
● Image processing services
● Intraoperative services
● Imaging supervision and interpretation services
● Observation services

APC of Soft tissue repair using anchor by Arthrex:

C: 代表outpatient的code HCPCS: 1個字母＋4個數字

CPT 23410跟 CPT 27650不同適應症對應的APC code都是5114 level 4 MSK，對於ASCs來說一樣給付金額，所以要做手術時間短的，降低手術成本，增加利潤！

OPPS Billing 流程：

Billing 方式

[1]https://www.psoriasis.org/advance/medicare-part-a-b-c-and-d-whats-the-difference/?gclid=CjwKCAjwvNaYBhA3EiwACgndgu5tQA1uS0c9LUrcNWs-NAF39k04ag7cZEkVjtDor6tEXdzTzlJiUxoCshcQAvD_BwE

[2]https://www.facs.org/advocacy/regulatory-issues/payment-rules/outpatient-prospective-payment-system/

[3]https://med.noridianmedicare.com/web/jea/provider-types/opps/opps-payment-status-indicators

[4]APCs, OPPS, DRG, RVUs名詞解釋: https://www.findacode.com/articles/understanding-apc-and-outpatient-payment-systems-35044.html#:~:text=APCs%20are%20used%20in%20outpatient,a%20separate%20or%20packaged%20code.