Changes to the OPPS Pricer Logic Effective January 1, 2003

50.6 - Changes to the OPPS Pricer Logic Effective January 1, 2003 (Rev. 1, 10-03-03) The following list contains a description of all OPPS Pricer logic changes that are effective beginning January 1, 2003. A. New OPPS wage indexes will be effective January 1, 2003. These are the same wage indexes that were implemented on October 1, 2002, for inpatient hospitals. Some corrections have been made since the publication of the inpatient rule and CMS are using the corrected wage indexes where applicable. B. Inpatient hospitals considered reclassified on October 1, 2002, will be considered reclassified for OPPS on January 1, 2003. C. Section 301 designations and floor MSA designations will be considered effective for OPPS on January 1, 2003. D. New payment rates and coinsurance amounts will be effective for OPPS on January 1, 2003. Some APCs have coinsurance amounts limited to 55 percent of the payment rate effective January 1, 2003. Some APCs have a coinsurance limit equal to the inpatient deductible of $840 effective January 1, 2003. E. If a claim has more than 1 service with a status indicator (SI) of T (SI of S has been removed from this rule) and any lines with SI T have less than $1.01 as charges, charges for all T lines will be summed and the charges will then be divided up proportionately to the payment rate for each T line. The new charge amount will be used in place of the submitted charge amount in the line item outlier calculation. EXAMPLE: SI Charges Payment Rate New Charges Amount T $19,999 $6,000 $12,000 T $1 $3,000 $ 6,000 T $0 $1,000 $ 2,000 $20,000 $10,000 $20,000 Because total charges here are $20,000 and the first SI of T gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 x $20,000 = $12,000. F. For outliers, CMS will change the factor multiplied times the total line item payments from 3.5 to 2.75 and the factor used to multiply the difference between line item payments and costs from .50 to .45. The CMS will eliminate the cost to charge ratio adjustment factor of .981956 from outlier and device calculations. G. Any claim having one or more APCs that match those listed in the Device Offset Table (Table 11) published in the November 1, 2002, “Federal Register” and a HCPCS code with status indicator (SI) H, will have all applicable APC offset amounts (multiplied by the number of units and the multiple procedure discount factor applicable to that line item) summed and wage adjusted. If there are more units of APCs with offset amounts than there are units of SI H devices that have an active (non-deleted) device category HCPCS code beginning with a C, i.e., those codes listed in section XXII B. of this PM, the total wage adjusted offset amount will be multiplied by the number of units of SI H devices that have a HCPCS code beginning with a C and then divided by the number of units of APCs with offset amounts. The total wage adjusted offset amount will then be subtracted proportionately from the charges reduced to costs for any SI H devices that have a HCPCS code beginning with a C. The pro rata reduction of 63.6 percent applicable to all SI G and/or H payments is eliminated.