CMS Outpatient PC Pricer – Some Vital Things to Know

 People get different types of insurance policies to choose from and make the choice as per their medical expenses and other requirements. By taking a medical insurance policy, you stay financially secured to bear the medical expenses that may arise due to unpredictable medical emergencies. But you must choose to buy a health insurance plan from a reliable and well-known insurance company to enjoy optimum benefits from the policy.

Both inpatient and outpatient medical services are provided by the hospitals or healthcare centers. The reimbursement amount that needs to be paid to the hospital for the outpatient healthcare services offered to the insured patients is decided by Medicare, and for this, a specific pricing system is followed, which is referred to as the Hospital Outpatient Prospective Payment System (OPPS). Here, you have to keep in mind that the prices of the medical services vary largely from place to place, and therefore, following a fixed and transparent pricing system is very important. To review, edit, and reprice the outpatient medical claims for reimbursement, the CMS Outpatient PC Pricer tool is used.

Furthermore, there is a particular coding system, known as the Healthcare Common Procedure Coding System (HCPCS). These codes are specifically given to different outpatient medical services and are revised and updated at least once in a year. It is important to note that in the present day, the Hospital Outpatient Prospective Payment System (OPPS) classifies all hospital outpatient services for the Medicare program into Ambulatory Payment Classifications or APCs.

The Importance of Using the CMS Outpatient PC Pricer

It is important to understand that not all the healthcare services offered to insured patients are considered to be appropriate for reimbursement. Some medical services are reimbursed only in the case of inpatient settings and not for outpatient cases. Therefore, to check the HCPCS codes by following which, the medical providers submit healthcare claims to Medicare, the CMS Outpatient PC Pricer tool is used in order to determine if a specific outpatient service can be considered reimbursable by the CMS. All PPS types of institutional and professional claims are repriced by using the CMS Outpatient PC Pricer as per the latest CMS policies.