Medicare Payments for Common Outpatient Procedures
Background:
This interactive database contains information about payments made by the Centers for Medicare and Medicaid Services (CMS) on behalf of Medicare beneficiaries to facilities (Hospital Outpatient and Ambulatory Surgery Centers) for a variety of commonly performed services in 2011. The procedures are listed by Current Procedural Terminology (CPT) code. (CPT codes are products, and CPT is a trademark, of the American Medical Association.)
The amounts that CMS pays Hospital Outpatient facilities (HOPD) and Ambulatory Surgery Centers (ASC) are largely based on a fee schedule derived from the Outpatient Prospective Payment System (OPPS). CMS groups services into ambulatory payment classifications (APC) on the basis of clinical and cost similarity so that services within a given APC have the same payment rate and each specific APC is assigned a “relative weight” compared to other APCs. The final total payment to the facility for an individual service uses this set of relative weights, a (dollar) conversion factor, and adjustments for geographic differences in input prices such as labor costs. Additions to the standard payment amount are sometimes made for “outlier” high-cost services, new technologies, and for rural sole community hospitals. In addition to paying the facility, CMS also pays separately for professional services (e.g., physician services) on behalf of its beneficiaries. In some cases, it might also reimburse the facility for ancillary services (e.g., drugs, blood products) that are not normally included within the APC primary service package.
Payment amounts for the same procedure made to these two types of facilities can vary since CMS assigns slightly different payment formulas (e.g., relative weights) to them. Additionally, facilities must meet other regulatory standards set out by CMS in order to be eligible to receive payment for a particular procedure.
First select the county (or counties) in which you are interested in seeing the payment information. (You may select multiple counties by holding the “Ctrl” key down while selecting additional counties.)
Next choose a “Facility Type” (there are two types) and the type of “Procedure” you’re interested in. Then click on “Show Results” to see a table containing the information.
Since CMS publishes slightly different payment information for the two facility types, the data fields shown after a search will differ depending on whether Hospital Outpatient or Ambulatory Surgery Center was chosen. Of course you can repeat the selection process for either facility type so that you can see both types of results. You can also sort the table of results by any data field by simply clicking on the field’s column heading. The table of results can be downloaded in Excel format by selecting “Export to Excel” after the results have been displayed.
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