Is Your Facility Prepared for the Mountain State BCBS Conversion to the Outpatient Prospective Payment System (OPPS)?

(PYA Alert dated January 10, 2008)


Effective for services rendered on or after January 1, 2008, MSBCBS will begin processing hospital outpatient claims under CMS’s Outpatient Prospective Payment System (“OPPS”). This will affect the following MSBCBS products:

• Traditional
• PPO
• POS
• FEP
• Steel

OPPS claims should be submitted on a UB claim form and follow Medicare billing guidelines. This transition will also bring an increased focus on accuracy of CPT/HCPCS code and modifier assignment as it relates to reimbursement and claims processing. To ease the conversion process, MSBCBS will adjust several OCE (Outpatient Code Editor) edits such as edit 18 (“inpatient procedure only”) as these may not be Medicare reimbursed but permissible under MSBCBS commercial plans.

Professional services (e.g., physician, CRNA) are not reimbursed under OPPS. MSBCBS will provide separate agreements to continue coverage of these services beginning January 1, 2008. All professional services should be submitted on a CMS 1500 claim form. If applicable, Partial Hospitalization and IOP (Intensive Outpatient) services will continue to be submitted under your hospital’s Partial Hospitalization Number, with rates remaining as negotiated in your Hospital Agreement.

Is your facility prepared for the changes that will result from MSBCBS’s conversion to OPPS?

PYA’s team of Clinical Compliance and Reimbursement professionals can assist you in assessing your compliance and reimbursement risks, targeting process improvement opportunities, and educating your staff to keep your organization in compliance. Please contact Denise Hall at (800) 270-9629 for additional details.

The information provided via PYA Alert, Tax Planning Alert, or Audit and Accounting Alert should not be construed as accounting, auditing, consulting, or legal advice on any specific facts or circumstances. The contents are intended for general information purposes only.  Please contact us at (800) 270-9629 to discuss your specific situation or to discuss any specific questions you may have.

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