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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

Resources

Last Updated Dec 14, 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.

Hospital OPPS July 2017 Update CR10122   May 31, 2017
Hospital OPPS April 2017 Update CR10005   Mar 13, 2017
Hospital OPPS - January 2017 Update CR9930   Jan 05, 2017
Hospital OPPS - October 2016 Update CR9768   Aug 30, 2016