Wiki Outpatient PPS

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jastewart

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For commercial payers are HCPCS Outpatient PPS codes routinely paid if the contract pays percent of charge? If yes, are all codes reimbursed, specifically when the SI is N? An example is C1776.
 
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jastewart said:
For commercial payers are HCPCS Outpatient PPS codes routinely paid if the contract pays percent of charge? If yes, are all codes reimbursed, specifically when the SI is N? An example is C1776.
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Do you mean the entire contract pays at a percent of charges for outpatient services? Or that there is a carveout for implants at a percent of charges?
 
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jastewart said:
entire contract
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If it is a commercial contract that pays at a percent of charges for outpatient services, then the CMS Outpatient PPS methodology shouldn't matter.

That being said, it's important to look at the language of the contractual agreement and any amendments/exhibits/communication that are part of the contract.

If the contract has specific language about implants, then that would override anything that I say below.

Based on my past experience working in managed care contracting departments, a very general summary of percent of charge contracts:

Typically a payer and provider enter into a percent of charges contract to make it easier to administer. For example, it could be a small payer that doesn't have a sophisticated claims processing system. Or a rural provider that doesn't get a lot of volume but the payer needs to keep in network for coverage purposes.

The payer usually isn't going to complicate processing by looking for PPS SI indicators, because ease of administration is usually the reason the parties entered into a percent of charges contract.

They might check for some basic unbundling edits to ensure the provider isn't padding the bill, and they may do some charge audits to ensure that the services charged on the claim actually match the documentation.

But they're not usually going to look at SI indicators unless the contract documents specifically state that PPS methodology will be used.
 
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Very good info in the post from @sls314 above, I agree with everything. Most percentage-of-charge contract do not employ PPS methodology and the status indicators would not be relevant. A status indicator N would mean that the payment is included in the case rate for the encounter, which would be meaningless if you're not being paid a case rate. But ultimately, this will all go back to the terms of your contract and the payer's policies, so that's where you'll need to look for an answer to this question.
One thing I'll add though is that it's possible single HCPCS codes could be denied on a claim is if the particular line item is not a covered benefit under the patient's particular plan. So you might see specific charges excluded from payment for this reason, with the remaining charges lines which are covered paid at the contract percentage.
 
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