********************************************* * 12/20/2011 RELEASE - V201211 * * Production * ********************************************* NOTE TO: Shared System Coordinators, MEDICARE Coordinators SUBJECT: Outpatient Prospective Payment System (OPPS) Pricer System Release, Version 201211 (January 1, 2012) --ACTION--refer to CMS change request CR #7672 This OPPS Pricer release is the updated version and is designed for implementaton in conjunction with the current OCE/APC V13.0 lines in the shared claims payment systems on or about 01Jan2012 and includes the following: - Corrected 2012 rates (APC & offets/reductions) - Corrected outlier threshold - ASP Drug rates effective 01/01/2012 added to APC table - Revised pass-through device offset logic to accommodate devices that have multiple procedure pairings with different effective and termination dates. - Revised pass-through offset logic to include the termination date as a valid date of service (pass-through contrast agents, devices, and radiopharmaceuticals). ********************************************** A partitioned data set of the Version 201211 code (MU00.@BF12390.OPPS.V201211.COBOL) is at the CMS Data Center for users to obtain by Connect:Direct (Network DataMover). The 41 members: 1 source program - OPPSCAL. 30 copybooks - OPPSWINX,OPPSWNXC,OPPSAPCS,OPPSOF02,OPPSOF03,OPPSOF04, OPPSOF06 OPPSOF07,OPPSOF08,DEVRED07,DEVRED08,OPPSMH08, OPPSPH08,DEVRED09,OPPSMH09,OPPSPH09,SSRFBN09,OPPSPTRH, OPPSPTRO,OPPSPTCH,OPPSPTCO,DEVRED10,OPPSMH10,OPPSPH10, SSRFBN10,SSRFB10B,OPPSPTDO,DEVRED11,DEVRED12,OPPSMH12 8 databooks - BASEAPCS,BASEWINX,BASEWNXC,BASEPTRH,BASEPTRO, BASEPTCH,BASEPTCO,BASEPTDO 2 text files - copy of this V201211 Release Memorandum and a list of the return codes (expanded by user notes) - V200MEMO,RTNCODES If you have any questions concerning this release or any other OPPS Pricer-related issues, please call Fred Rooke at (404) 562-7205. Tamara E. Howard Computer Specialist/Systems Analyst Division of Data Systems CMS/CMM/PBG/DDS OPPS Pricer Release V201211 Notes: Page 1 of 2 Below are brief descriptions of the OPPS Pricer modules in Version 201211 of the system plus a copy of the Linkage Section and the CALL statement needed to access the module. BASEAPCS - human-readable data from which the OPPSAPCS copybook is built BASEPTCH - human-readable data from which the OPPSPTCH copybook is built BASEPTCO - human-readable data from which the OPPSPTCO copybook is built BASEPTDO - human-readable data from which the OPPSPTDO copybook is built BASEPTRH - human-readable data from which the OPPSPTRH copybook is built BASEPTRO - human-readable data from which the OPPSPTRO copybook is built BASEWINX - human-readable data from which the OPPSWINX copybook is built BASEWNXC - human-readable data from which the OPPSWNXC copybook is built DEVRED07 - copybook of 2007 device reduction APCs and reduction amounts DEVRED08 - copybook of 2008 device reduction APCs and reduction amounts DEVRED09 - copybook of 2009 device reduction APCs and reduction amounts DEVRED10 - copybook of 2010 device reduction APCs and reduction amounts DEVRED11 - copybook of 2011 device reduction APCs and reduction amounts DEVRED12 - copybook of 2012 device reduction APCs and reduction amounts OPPSAPCS - copybook of APC groups for OPPSCAL, expanded to include additional APC groups OPPSCAL - source code for OPPS pricing subroutine OPPSMH08 - copybook of CY 2008 mental health HCPCS OPPSMH09 - copybook of CY 2009 mental health HCPCS OPPSMH10 - copybook of CY 2010 mental health HCPCS OPPSMH12 - copybook of CY 2012 mental health HCPCS OPPSOF02 - copybook of device APC groups with an offset amount, for SI ' H' processing for OPPSCAL for 2002 OPPSOF03 - copybook of device APC groups with an offset amount, for SI ' H' processing for OPPSCAL for 2003 OPPSOF04 - copybook of device APC groups with an offset amount, for SI ' H' processing for OPPSCAL for 2004, 2005 OPPSOF06 - copybook of device APC groups with an offset amount, for SI ' H' processing for OPPSCAL for 2006 OPPSOF07 - copybook of device APC groups with an offset amount, for SI ' H' processing for OPPSCAL for 2007 OPPSOF08 - copybook of device APC groups with an offset amount, for SI ' H' processing for OPPSCAL for 2008 OPPSPH08 - copybook of CY 2008 partial hospitalization HCPCS OPPSPH09 - copybook of CY 2009 partial hospitalization HCPCS OPPSPH10 - copybook of CY 2010 partial hospitalization HCPCS OPPSPTCH - copybook of pass-through contrast agent hcpcs for OPPSCAL OPPSPTCO - copybook of pass-through contrast agent offsets for OPPSCAL OPPSPTDO - copybook of pass-through device offsets for OPPSCAL OPPSPTRH - copybook of pass-through radiopharm. hcpcs for OPPSCAL OPPSPTRO - copybook of pass-through radiopharm. offsets for OPPSCAL OPPSWINX - copybook of wage indices by MSA for OPPSCAL OPPSWNXC - copybook of wage indices by CBSA for OPPSCAL RTNCODES - list of OPPS Pricer claim and line level return codes SSRFBN09 - copybook of CY 2009 state-specific rural floor budget neutrality (SSRFBN) factors SSRFBN10 - copybook of CY 2010 state-specific rural floor budget neutrality (SSRFBN) factors: 01/01/2010 - 06/30/2010 SSRFB10B - copybook of CY 2010 state-specific rural floor budget neutrality (SSRFBN) factors: 07/01/2010 - 12/31/2010 V200MEMO - copy of this memorandum This is the LINKAGE SECTION defined in OPPSCAL. LINKAGE SECTION. *************************************************************** * LAYUP TABLE AREA FOR PROVIDER SPECIFIC RECORD * *************************************************************** 01 L-PROV-SPEC-AREA. 05 L-PSF-NPI PIC X(08). 05 L-PSF-NPI-FILLER PIC X(02). 05 L-PSF-PROV-OSCAR. 10 L-PSF-PROV-ST PIC X(02). 10 L-PSF-PROV-3456 PIC X(04). 05 L-PSF-EFFDT PIC 9(08). 05 L-PSF-FY-BEGIN-DT PIC 9(08). 05 L-PSF-REPORT-DT PIC 9(08). 05 L-PSF-TERMDT PIC 9(08). 05 L-PSF-WAIVE-IND PIC X(01). 05 L-PSF-FI-NUM PIC 9(05). 05 L-PSF-PROV-TYPE PIC X(02). 05 L-PSF-SPCL-LOCATION-IND PIC X(01). 05 L-PSF-WGIDX-RECLASS PIC X(01). 05 L-PSF-GEO-MSA PIC X(04). 05 L-PSF-WI-MSA PIC X(04). 05 L-PSF-COLA PIC 9V9(03). 05 L-PSF-STATE-CODE PIC 9(02). 05 L-PSF-TOPS-INDICATOR PIC X(01). 05 L-PSF-HOSP-QUAL-IND PIC X(01). 05 FILLER PIC X(01). 05 L-PSF-OPCOST-RATIO PIC 9V9(03). 05 L-PSF-GEO-CBSA PIC X(05). 05 L-PSF-WI-CBSA PIC X(05). 05 L-PSF-SPEC-WGIDX PIC 9(02)V9(04). 05 L-PSF-SPEC-PYMT-IND PIC X(01). 05 L-PSF-APC-LINE-CNT PIC 9(04). 05 L-PSF-APC-TABLE OCCURS 999 TIMES DEPENDING ON L-PSF-APC-LINE-CNT. 10 L-PSF-APC PIC X(04). 10 L-PSF-RED-COIN PIC 9(04)V99. *************************************************************** 00000100 * INPUT RECORD FROM THE OCE/STANDARD SYSTEM * *-------------------------------------------------------------* * BELOW ARE THE VARIABLES THAT WILL BE PASSED * * TO PRICER FROM THE OCE BEGINNING OCT. 1, 2005 THERE WILL BE * * - INCREASED SIZE OF SERVICE AND PAYMENT - 1 TO 2 BYTES * * - INCREASED SIZE OF PYMT ADJUSTMENT FLAG - 1 TO 2 BYTES * * CY 2009 EDITS - MADE 11/10/2008: * * - INCREASED SIZE OF SERVICE UNITS - 7 TO 9 BYTES * * - ADDED COMPOSITE ADJUSTMENT FLAG - 2 BYTES * *************************************************************** 01 OPPS-LINE-CNT PIC 9(08) COMP. 01 OCE-DATA. 05 OPPS-OCE-LINE OCCURS 450 TIMES DEPENDING ON OPPS-LINE-CNT. 10 OPPS-HCPCS. 15 OPPS-ALPHA PIC X(01). 15 FILLER PIC X(04). 10 OPPS-GRP. 15 FILLER PIC X(01). 15 OPPS-APC PIC X(04). 10 OPPS-HCPCS-APC PIC X(05). 10 OPPS-SRVC-IND PIC X(02). 10 OPPS-PYMT-IND PIC X(02). 10 OPPS-DISC-FACT PIC 9(01). 10 OPPS-LITEM-DR-FLAG PIC X(01). 10 OPPS-PKG-FLAG PIC X(01). 10 OPPS-PYMT-ADJ-FLAG PIC X(02). 10 OPPS-SITE-SRVC-FLAG PIC X(01). 10 OPPS-SRVC-UNITS PIC 9(09). 10 OPPS-SUB-CHRG PIC 9(08)V99. 10 OPPS-LITEM-ACT-FLAG PIC X(01). 10 OPPS-COMP-ADJ-FLAG PIC X(02). 01 L-SERVICE-FROM-DATE PIC 9(08). 01 BENE-DEDUCT PIC 9(03)V9(02). 01 BENE-BLOOD-PINTS PIC 9(01). *************************************************************** * BELOW ARE THE VARIABLES THAT WILL BE PASSED BACK * * TO SS ASSOCIATED WITH THE BILL BEING PROCESSED * * - EFF. 04/01/2002 CALCULATE LINE ITEM OUTIER PAYMENT * *************************************************************** 01 A-ADDITIONAL-VARIABLES. 05 A-CALC-VERS PIC X(07). 05 A-TOTAL-CLM-DEDUCT PIC 9(03)V9(02). 05 A-OUTLIER-PYMT PIC 9(07)V9(02). 05 A-TOT-CLM-PYMT PIC 9(07)V9(02). 05 A-TOT-CLM-CHRG PIC 9(07)V9(02). 05 A-CLM-RTN-CODE PIC 9(02). 05 A-MSA PIC X(04). 05 A-CBSA PIC X(05). 05 A-WINX PIC S9V9(04). 05 A-BLOOD-PINTS-USED PIC 9(01). 05 A-BLOOD-DEDUCT-DUE PIC 9(05)V9(02). 05 A-LINE-ITEMS OCCURS 450 TIMES DEPENDING ON OPPS-LINE-CNT. 10 A-LITEM-PYMT PIC 9(07)V9(02). 10 A-LITEM-REIM PIC 9(07)V9(02). 10 A-TOTAL-LN-DEDUCT PIC 9(03)V9(02). 10 A-ADJ-COIN PIC 9(05)V9(02). 10 A-RED-COIN PIC 9(05)V9(02). 10 A-BLOOD-LN-DEDUCT PIC 9(05)V9(02). 10 A-RETURN-CODE PIC 9(02). 01 OCE-IN-DATE. 05 OCE-IN-LINES OCCURS 450 TIMES. 10 FILLER PIC X(15). 10 OPPS-LITEM-DOS PIC 9(08). 10 FILLER PIC X(23). * 10 FILLER PIC X(21). CHANGED 12/2/2008 Data Descriptions: A-CALC-VERS - OPPSCAL release version A-TOTAL-CLM-DEDUCT - Total deductible applied the claim A-OUTLIER-PYMT - Outlier payment for the claim associated with the OPPS lines A-TOT-CLM-PYMT - Total claim payment amount used to calculate the outlier amount A-TOT-CLM-CHRG - Total claim charge amount used to calculate the outlier amount A-CLM-RTN-CODE - Claim level return code A-MSA - MSA for claim A-CBSA - CBSA for claim A-WINX - Wage Index for claim ********************************* * A-LINE-ITEMS OCCURS 450 TIMES * * DEPENDING ON OPPS-LINE-CNT.* ********************************* A-LITEM-PYMT - Total adjusted line payment A-LITEM-REIM - Medicare program payment amount A-TOTAL-LN-DEDUCT - Total deductible applied to the line A-ADJ-COIN - Adjusted coinsurance amount A-RED-COIN - Provider elected coinsurance or minimum coinsurance allowed ; which ever is greatest A-BLOOD-LN-DEDUCT - Total blood deductible applied to the line A-RETURN-CODE - Line level retun code *************************************************************** * PROCESSING: * * Below is the CALL STATEMENT and variables listed * * required by the OPPSCAL module. * *************************************************************** CALL OPPSCAL USING OPPS-LINE-CNT OCE-DATA A-ADDITIONAL-VARIABLES L-PROV-SPEC-AREA L-SERVICE-FROM-DATE BENE-DEDUCT BENE-BLOOD-PINTS OCE-IN-DATE.