AHA Coding Clinic® for HCPCS - 2005 Quarter 3; FOR your INFORMATION
Reprocessing of OPPS claims containing surgical procedures
An error was discovered in the 2005 OPPS PRICER that miscalculated the outlier payment amount. The error was corrected in the July 2005 version of the OPPS PRICER. By September 15, 2005, FI’s should mass adjust all claims that meet all of the following criteria using the corrected July 2005 OPPS PRICER: 1. Claims were processed using the January or April 2005 OPPS PRICER prior to the July 2005 OPPS PRICER installation; and 2. Claims with one or more surgical procedure lines (lines with status indicator of “T” or “S” with HCPCS codes greater than 09999...
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Article Overview
This article covers a correction to a pricing error in the 2005 OPPS PRICER and the resulting reprocessing of affected outpatient claims. It is relevant to hospital outpatient billing staff, reimbursement teams, and coders who monitor OPPS edits, claim adjustment activity, and time-bound implementation guidance from CMS. The article focuses on the affected claim characteristics, the timing of the correction, and the administrative action needed for mass adjustment.
Why This Topic Matters
Understanding which OPPS claims were impacted by the corrected pricing logic helps providers identify claims subject to reprocessing and avoid payment discrepancies tied to the 2005 update.
What You Will Learn
- What issue was identified in the OPPS pricing process
- What type of claims fell within the reprocessing scope
- How the article frames the timing of the correction and adjustment activity
- Which broad claim characteristics were used to identify affected claims
Who Should Read This
- Hospital outpatient billing staff
- Revenue cycle and reimbursement teams
- Medical coders
- Compliance and claims processing personnel
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