Outpatient Prospective Payment System (OPPS)
The OPPS was implemented in 2000 and significantly changes how hospitals are reimbursed for outpatient services under Medicare.
Services Included Under OPPS
- Designated hospital outpatient services
- Certain Medicare Part B services furnished to hospital inpatients who do not have Part A coverage
- Partial hospitalization services furnished by hospitals or Community Mental Health Centers (CMHC)
- Hepatitis B vaccines and their administration, splints, casts, and antigens furnished by a Home Health Agency (HHA) to patients who are not under an HHA plan of treatment or to hospice patients for treatment of non-terminal illness
- An initial preventive physical examination (IPPE) performed within the first 12 months of Medicare Part B coverage
Services Excluded from Payment under OPPS
- Clinical diagnostic laboratory services
- Outpatient therapy services
- Screening and diagnostic mammography
- CMS Addendum A and B Updates - Updates reflect the OPPS Pricer changes that are part of the quarterly OPPS recurring update notification transmittals.
- CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS
- CMS OCE/Device Procedure Edits
- CMS OPPS National Correct Coding Edits
- CMS OPPS Guidance - Contains guidance related to OPPS policy transmittals, regulations, and notices.
Last Updated Nov 28, 2017
The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.