I was able to compare payment methodologies in different settings. As part of my hospital OPPS(Outpatient Prospective Payment System) case project, which classifies all hospital outpatient services into Ambulatory Payment Classification, I learned that applying correct diagnosis codes for medical necessities as well as applying correct CPT procedure codes with modifiers to calculate APC is an important step in proper reimbursement. APC is calculated by multiplying the APCs relative weight by OPPS conversion factor and minor adjustment for geographic location.

I was able to collect information from Addendum-B and -D to lookup for correct APCs and relative weight for outpatient coding cases. Additionally, I learned that OPPS is applicable only to hospital and have no impact on physician payments under the Medicare physician fee schedule.

In inpatient case studies, I was able to assign correct DRGs which is a Diagnosis Related Group - patient classification system that standardizes prospective payment to hospitals. I learned that correct DRG with CC/MCC can hugely impact on hospital reimbursement so determining correct principle diagnosis is most important step in coding process.

In my organizational management statistics assignment, I successfully calculated correct DRGs to determine the revenue comparisons for same hospitals based on DRG factors.

Artifacts:

Hospitals OPPS case study

Organizational Management statistics case study

Hospital IPPS case study

Clintegrity case study