Payment systems

Medicare uses different payment systems depending on the type of facility and setting. The L2 (Facility Type) layer in RCI determines which payment system applies.

Payment systems

MPFS — Medicare Physician Fee Schedule

Attribute	Value
Applies to	Professional services (physician office, clinic)
Payment method	RVU × GPCI × Conversion Factor
Billing form	CMS-1500 / 837P

MPFS is the most common payment system. Payment is calculated using Relative Value Units (RVUs) adjusted by Geographic Practice Cost Indices (GPCIs) and multiplied by the annual conversion factor.

OPPS — Outpatient Prospective Payment System

Attribute	Value
Applies to	Hospital outpatient services
Payment method	Ambulatory Payment Classification (APC) based
Billing form	UB-04 / 837I

OPPS groups outpatient services into APCs with set payment rates. Separate payment for drugs, devices, and pass-through items.

IPPS — Inpatient Prospective Payment System

Attribute	Value
Applies to	Acute care hospital inpatient stays
Payment method	Diagnosis Related Group (DRG) based
Billing form	UB-04 / 837I

IPPS pays a fixed amount per inpatient discharge based on the DRG, adjusted for hospital characteristics (teaching, DSH, outliers).

Other payment systems

System	Applies To
HH PPS	Home health episodes
SNF PPS	Skilled nursing facility stays
IRF PPS	Inpatient rehabilitation facilities
Hospice	Hospice care (per diem rates)
CAH	Critical Access Hospitals (cost-based)

RCI and payment systems

RCI determines the applicable payment system from the facility’s CCN:

curl https://api-dev.rcintell.com/v1/knowledge/layers/170001/l2 \
  -H "X-API-Key: kp_test_..."

Response includes:

{
  "layer": "l2_facility_type",
  "facility_type": "Short-term Hospital",
  "payment_systems": {
    "outpatient": "OPPS",
    "professional": "MPFS",
    "inpatient": "IPPS"
  },
  "billing_form": "CMS-1500 / 837P"
}

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Payment systems

Payment systems

MPFS — Medicare Physician Fee Schedule

OPPS — Outpatient Prospective Payment System

IPPS — Inpatient Prospective Payment System

Other payment systems

RCI and payment systems

​Payment systems

​MPFS — Medicare Physician Fee Schedule

​OPPS — Outpatient Prospective Payment System

​IPPS — Inpatient Prospective Payment System

​Other payment systems

​RCI and payment systems

Payment systems

MPFS — Medicare Physician Fee Schedule

OPPS — Outpatient Prospective Payment System

IPPS — Inpatient Prospective Payment System

Other payment systems

RCI and payment systems