OPPS Calculator Outlier Payments

The OPPS (Outpatient Prospective Payment System) Calculator module is a pre/post bill analysis and research tool for hospital outpatient claims that assists with the constantly changing reimbursement rules.

OPPS Calculator includes coding and reimbursement analysis using the rules that were or are in effect for the date of the claim; wage and locality adjustment payment rates; I/OCE edits including special processing conditions applied to outpatient claims; outlier reimbursement where appropriate and details of potential line item/claim level denials or rejections.

Accessing OPPS Calculator

OPPS Calculator is accessed via Products > VitalKnowledge > CodeValidate.

OPPS Calculator Input

• When you click Validate, the results are calculated and made available in OPPS Calculator grid on the right side of the screen under the Outlier Payment column.

OPPS Calculator Output

Disclaimer: Reimbursement information is gathered from the CMS website and is presented for illustrative purposes only. This information provides no assurance of coverage or reimbursement and does not constitute official coding or billing guidance. This information reflects payment estimates only and is not a guarantee of payment. VitalWare makes no guarantee regarding this information or its applicability with respect to any particular patient or third party payer. Service providers are responsible for their decisions related to coding and reimbursement submissions based on the official regulations and other interpretive materials as necessary.