Wiki OPPS Facility/Non-Facility vs MPFS Facility/Non-Facility Rate

[jporter74]

I'm doing some research for a project and am generally a coding newbie. I'm trying to understand what the OPPS Facility/Non-Facility payment amount is referring to. For instance, for code 33208 (Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular) I see the following under OPPS

OPPS Non-Facility Payment Amount: $288.72
OPPS Facility Payment Amount: $288.72

Under the MPFS I see

MPFS Non-Facility Payment Amount: $519.15
MPFS Facility Payment Amount: $519.15

What payment is being referred to within the OPPS? Under what conditions would that be paid? Any guidance?

 

[thomas7331]

Where are you finding these OPPS payment amounts? OPPS is for payments to facilities only so there no such thing as an ‘OPPS Non-Facility Payment Amount’. Not sure where that’s coming from.

MPFS is for physician fees, which vary depending on the location. The fee for 33208 is the same for both because that procedure would never be done outside of a facility.

 

[Mrsrpc]

OPPS is for the hospital outpatient dept to receive payment for the use of the surgical suite (or endo suite, etc) and equipment. MPFS is for the physician's time and skill to be reimbursed.

 

[jporter74]

That's why I'm so confused. But look up that procedure in the OPPS tool on Codify, and you'll see that number. Could it just be the physician component of the bundled APC payment? Or again, the bundled APC payment would just be the facility fee. But sounds like I should just ignore it.

On a separate note, any guidance on where I could generate a list of cardiology procedures and what sites they are approved for or likely to be performed in? I downloaded the OPPS ASC Addenda, which is exhaustive, but it's not helpful in identifying which procedures are likely to be done in an office and which CPT codes could be done in an office AND an ASC, and which are just likely to be done in an office or ASC.

 

[thomas7331]

That's why I'm so confused. But look up that procedure in the OPPS tool on Codify, and you'll see that number. Could it just be the physician component of the bundled APC payment? Or again, the bundled APC payment would just be the facility fee. But sounds like I should just ignore it.

On a separate note, any guidance on where I could generate a list of cardiology procedures and what sites they are approved for or likely to be performed in? I downloaded the OPPS ASC Addenda, which is exhaustive, but it's not helpful in identifying which procedures are likely to be done in an office and which CPT codes could be done in an office AND an ASC, and which are just likely to be done in an office or ASC.

I've never used Codify, so I'm not sure why they've included these OPPS amounts. There's no physician component to an APC payment, so it's not that. Under OPPS, the facility is not paid on a fee schedule but at a composite rate which requires looking at the entire claim as a whole, not individual lines, so there's no fixed rate per CPT code. So it doesn't make any sense to me why Codify would be attaching an OPPS rate to a particular code. I would just ignore that piece of information, to be honest.

I don't know where to find lists of what codes can be performed in what sites, and I'm not sure there really is such a list. The ASC file will give you the indicators that tell whether or not a procedure is reimbursed in an ASC, but there's no equivalent listing for office vs. facility procedures. Even if there were, it would probably vary a lot from payer to payer. But if you use the Medicare Physician Fee Schedule, which you can download, you can easily see for any given code if there is a site of service differential (i.e. a higher payment rate in the office than for a facility for that procedure), and that will tell you if the procedure is generally done in both office and facility or only in a facility. If the facility and non-facility rates are the same, that means there's no additional reimbursement for an office because the procedure is almost always performed in a facility and no separate office rate has been set up.

 

[jporter74]

I've never used Codify, so I'm not sure why they've included these OPPS amounts. There's no physician component to an APC payment, so it's not that. Under OPPS, the facility is not paid on a fee schedule but at a composite rate which requires looking at the entire claim as a whole, not individual lines, so there's no fixed rate per CPT code. So it doesn't make any sense to me why Codify would be attaching an OPPS rate to a particular code. I would just ignore that piece of information, to be honest.

I don't know where to find lists of what codes can be performed in what sites, and I'm not sure there really is such a list. The ASC file will give you the indicators that tell whether or not a procedure is reimbursed in an ASC, but there's no equivalent listing for office vs. facility procedures. Even if there were, it would probably vary a lot from payer to payer. But if you use the Medicare Physician Fee Schedule, which you can download, you can easily see for any given code if there is a site of service differential (i.e. a higher payment rate in the office than for a facility for that procedure), and that will tell you if the procedure is generally done in both office and facility or only in a facility. If the facility and non-facility rates are the same, that means there's no additional reimbursement for an office because the procedure is almost always performed in a facility and no separate office rate has been set up.

Okay. I'll just ignore it. I'm trying to attach a screenshot of Codify OPPS output to show you, but running into errors, but I'll ignore it.

Great insight regarding letting the code differentiation be a guide on where it can be performed. Thank you for your help!

One more question, If I download the physician fee schedule for a block of CPT codes, will it be include every available CPT code within the block? Is the MPFS exhaustive in that sense? Otherwise, I'm not sure where to find a complete list of CPT codes, other than browsing/navigating AAPC's website section and subsection by section and subsection.

Thanks again!

 

[thomas7331]

Okay. I'll just ignore it. I'm trying to attach a screenshot of Codify OPPS output to show you, but running into errors, but I'll ignore it.

Great insight regarding letting the code differentiation be a guide on where it can be performed. Thank you for your help!

One more question, If I download the physician fee schedule for a block of CPT codes, will it be include every available CPT code within the block? Is the MPFS exhaustive in that sense? Otherwise, I'm not sure where to find a complete list of CPT codes, other than browsing/navigating AAPC's website section and subsection by section and subsection.

Thanks again!

I think the MPFS should include all of the CPT and HCPCS codes but many of them won't have pricing or any reimbursement information, e.g. unlisted codes, codes for non-covered service, those codes that are priced on different fee schedule, carrier priced codes, etc.

 

[jporter74]

I think the MPFS should include all of the CPT and HCPCS codes but many of them won't have pricing or any reimbursement information, e.g. unlisted codes, codes for non-covered service, those codes that are priced on different fee schedule, carrier priced codes, etc.

Thanks again. You've been very helpful!