Medicare payment calculations


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Our Workers Compensation follows the Medicare OPPS guidelines and status indicators for payment. At this time I need to manually calculate the payments. Reading the OPPS guidelines 10.4.1 Combinations of Packaged Services of Different types that are furnished on the same date of service, when there are multiple Q1 or Q2 status indicators on a claim and the claim does not contain a S, T, V or X status indicator only one of the Q1 or Q2 codes would get paid.

1. Am I interpreting this correctly?
2. Is there a software program that I could use to enter the data to see how Medicare would pay a claim?


True Blue
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You're interpreting it correctly - the codes with Q1 & Q2 are 'conditionally packaged' to codes in those other categories, or if there isn't one of those status codes on the claim, then they would package to the highest priced APC of the other conditionally packaged code if there is more than one.

There are a number of good software programs that will do this for you - if you a search for 'APC facility encoders' you'll find a number. 3M and Webstrat are two that I'm familiar with that are widely used and also have the advantage of options that can interface with your billing system an automate the process of having to manually key information. I've noticed too that CMS has a software package that you can purchase directly from them via their Medicare OPPS page, but I don't know much about what that offers.