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Response to lead student discussion post. below is the post that needs a written response to
I choose to present the Title XVIII of the Social Security Act, designated “Health Insurance for the Aged and Disabled,” commonly known as Medicare. This regulation was enacted to ensure Medicare and its beneficiaries pay appropriately for services and to encourage more efficient delivery of care. Congress mandated replacement of the reasonable cost-based payment methodology used by outpatient hospitals with a prospective payment system (PPS). The Balanced Budget Act of 1997 (BBA) (Pub. L. 105–33) added section 1833(t) to the Act, authorizing implementation of a PPS for hospital outpatient services. The OPPS was first implemented for services furnished on or after August 1, 2000 with regulations located at 42 CFR parts 410 and 419.
Payments for OPPS procedures, services, and items are generally based on medical billing codes, specifically, HCPCS codes, that are reported on Hospital Outpatient Department claims. The basic methodology for determining prospective payment rates for Hospital Outpatient Department (HOPD) services under the OPPS is set forth in existing regulations at 42 CFR part 419, subparts C and D. In essence, HCPCS codes are used to report surgical procedures, medical services, items, and supplies under the hospital OPPS. HCPCS codes are divided into two principal subsystems, referred to as Level I and Level II. Together, Level I and II HCPCS codes are used to report procedures, services, items, and supplies under the OPPS payment system.
The Office of the Inspector General (OIG), under the Department of Health and Hospitals issued Federal Register, Volume 70, No.19 as a supplemental compliance guide for hospitals. It specifically addresses the Hospital OPPS system beginning at page 4860 (Outpatient Procedure Coding) to guide hospitals in developing, monitoring and surveilling compliance based on complete medical records and moreover, medical records that support the levels of services claimed.
Resources:
CY 2023 Hospital Outpatient PPS Policy Changes and Payment Rates and Ambulatory Surgical Center Payment System Policy Changes and Payment Rates. Department of Health and Human Services, CMS. Retrieved April 2, 2024, from https://www.federalregister.gov/documents/2022/11/23/2022-23918/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment
Centers for Medicare & Medicaid Services (2009, November 1). Brief Summaries of Medicare & Medicaid. Title XVIII and Title XIX of the Social Security Act. Retrieved April 2, 2024, from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicareprogramratesstats/downloads/medicaremedicaidsummaries2009.pdf
Office of Inspector General (OIG), HHS (n.d.). Federal Register/Vol.70, No.19 Notices. OIG Supplemental Compliance Program Guidance for Hospitals. https://oig.hhs.gov/documents/compliance-guidance/797/012705HospSupplementalGuidance.pdf
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