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The OPPS is an Ambulatory Payment Classification (APC) system for covered hospital-based outpatient services. It consists of groups of covered services arranged so services within each group are comparable clinically and with respect to the use of resources. Level I Current Procedural Terminology (CPT) and Level II Healthcare Common Procedure Coding System (HCPCS) codes and descriptors are used to identify and group the services within each APC. Costs associated with items or services that are directly related and integral to performing a procedure or furnishing a service have been packaged into each procedure or service within an APC group.
While the TRICARE OPPS is modeled after the Medicare OPPS, there are some differences between the two systems, such as covered benefits and beneficiary copayments. The TRICARE Outpatient Code Editor (OCE) will reflect these differences, allowing payment for those services that are covered under TRICARE, but not under Medicare and vice versa. In addition, TRICARE will retain its current hospital outpatient deductibles, cost-share and copayment amounts and catastrophic loss protection under its OPPS.
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Currently, when sufficient coding information is provided, outpatient hospital services, including emergency services, clinical laboratory services, rehabilitation therapy, venipuncture and radiology services are paid using existing allowable charges. Such services are reimbursed under the allowable charge methodology that would also include the CHAMPUS Maximum Allowable Charge (CMAC) rates for professional services. Other services without allowable charges, such as facility charges, are paid as a percentage of billed charges.
Under the new OPPS, each procedure code will be assessed on a line-by-line basis in determining its appropriate reimbursement. The claims data will be processed through the TRICARE-specific OCE to determine final reimbursement. Procedure codes (HCPCS codes/CPT-4 codes) applied to a particular APC group will be reimbursed at the pre-determined, geographically wage-adjusted fee-for-service payment. Other procedure codes will either be bundled to primary procedure codes (with which they are normally associated), paid separately (under another fee schedule or payment system other than OPPS), or denied. Total claim reimbursement will be the sum of the individual procedure payments (e.g., wage-adjusted APC amounts or CMAC payment rates) less the beneficiary’s appropriate deductible and cost-share.
Look to future issues of TRICARE Provider News for the latest information about the new TRICARE OPPS. Future articles will include useful information about the common differences between Medicare and TRICARE OPPS and identify provider categories included/excluded in the TRICARE OPPS.
To access additional information regarding the TRICARE OPPS program, please refer to the TRICARE Reimbursement Manual, Chapter 13.
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