All information in
this report is taken from the Medicare Outpatient Prospective
Payment System (OPPS)
Limited Data Set which is updated annually by CMS based on the
calendar year. The file includes billing data for 100% of
all Medicare fee-for-service claims for hospital outpatient
services during the
twelve months ending December 31. The report is based on
the most recent period available and is consistent with
CMS
cell size suppression policy.
The twenty primary
ICD-9 diagnosis codes with the highest levels of payment are
ranked by total payment and all others are summarized. All
averages in the report are calculated on a per claim basis.
Claims without a diagnosis coded are excluded:
- Total
Payment - the computed OPPS payment for a line item based on
the payment APC. The "payment APC" refers to total payment,
including deductible, coinsurance, and program payment.
Payment also includes outlier amounts..
- Number
Patient Claims - the total number of claims with the primary
diagnosis.
- Average
Charge - the total charges (covered and non-covered) for all
accommodations and services (related to the revenue code)
for a billing period before reduction for the deductible and
coinsurance amounts and before an adjustment for the cost of
services provided.
- Average
Cost - Charges adjusted to cost using the hospital's
specific cost center cost-to-charge ratio.
This calculation is done by CMS and included with OPPS claims data. (Details of the calculation are not provided by CMS.)
- Average
Payment - The computed OPPS payment for a line item based on
the payment APC. The "payment APC" refers to total payment,
including deductible, coinsurance, and program payment.
Payment also includes outlier amounts.
- Total
Outlier Amount - Total Medicare outlier payments. (Included
in Total Payment.)
- National
Average Charge - Computed national average charge for all US
hospitals.