What is the total APC payment for HCPCS codes 66984, 71020, and 78740? Round the answer to two decimal points. Explain. You attended an in-service education program about the outpatient prospective payment system (OPPS) where you learned that certain Medicare Part B services are paid according to ambulatory payment classifications (APCs), which group services according to similar clinical characteristics and in terms of resources required. A payment rate is established for each APC and, depending on services provided, hospitals may be paid for more than one APC for a patient encounter. As part of the in-service, you are provided with the following information and required to answer each question by applying the formula to calculate APC payments. Outpatient Prospective Payment System (OPPS) Formula: (APC Weight * Conversion Factor * Wage Index) + Add-On Payments = Payment NOTE: When a patient undergoes multiple procedures and services on the same day, multiple APCs are generated and payments are added together. APC software automatically discounts multiple APC payments when appropriate (e.g., bilateral procedure). Conversion Factor = $80.79 Wage Index = 0.9445 HCPCS Code 66984 71046 78740 Description Cataract procedure with intraocular lens implant Chest x-ray, 2 views Ureteral reflux study APC 246 260 292 APC Weight 24.56 1.56 3.94
The Correct Answer and Explanation is:
To calculate the total APC payment for HCPCS codes 66984, 71046, and 78740, we will apply the OPPS payment formula: Payment=(APC Weight×Conversion Factor×Wage Index)+Add-On Payments\text{Payment} = (\text{APC Weight} \times \text{Conversion Factor} \times \text{Wage Index}) + \text{Add-On Payments}
Given:
- Conversion Factor = $80.79
- Wage Index = 0.9445
- Add-On Payments = 0 (not specified, so we assume 0)
Step-by-Step Calculation:
1. HCPCS Code 66984 (Cataract procedure with intraocular lens implant)
- APC Weight = 24.56
24.56×80.79×0.9445=1,872.3624.56 \times 80.79 \times 0.9445 = 1,872.36
2. HCPCS Code 71046 (Chest x-ray, 2 views)
Note: The correct HCPCS code in the question is 71020, but the table lists 71046—a more current code. We’ll use 71046 as per the details provided.
- APC Weight = 1.56
1.56×80.79×0.9445=118.941.56 \times 80.79 \times 0.9445 = 118.94
3. HCPCS Code 78740 (Ureteral reflux study)
- APC Weight = 3.94
3.94×80.79×0.9445=300.633.94 \times 80.79 \times 0.9445 = 300.63
Total APC Payment:
1,872.36+118.94+300.63=2,291.931,872.36 + 118.94 + 300.63 = \boxed{2,291.93}
Explanation :
In the outpatient setting, Medicare reimburses hospitals using the Outpatient Prospective Payment System (OPPS). This system relies on Ambulatory Payment Classifications (APCs), which group procedures with similar resource usage. Each HCPCS (Healthcare Common Procedure Coding System) code is assigned an APC weight, which, when multiplied by a conversion factor and adjusted for local labor costs via a wage index, yields the Medicare payment amount for that service.
In this scenario, we are calculating total payment for three HCPCS codes provided during a single patient encounter: a cataract procedure (66984), a chest x-ray (71046), and a ureteral reflux study (78740). Each code has a corresponding APC weight:
- 66984: 24.56
- 71046: 1.56
- 78740: 3.94
Using the OPPS formula, we multiply each APC weight by the conversion factor of $80.79 and the wage index of 0.9445. Since no add-on payments are specified, we assume they are zero. The result of each calculation gives the Medicare payment for that service. Adding these payments together gives the total APC payment, as Medicare reimburses separately for each service provided on the same day unless bundling or discounting rules apply, which were not specified here.
The final result is $2,291.93, representing the total OPPS-based reimbursement for all three procedures.
