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The OPPS versions contain claims from hospitals that are paid under the outpatient prospective payment system (OPPS). Hospitals that are not paid under OPPS include: Critical Access Hospitals, Indian Health Service hospitals, and hospitals located in American Samoa, Guam, Saipan, and the Virgin Islands. OPPS also applies to partial hospitalization services furnished by Community Mental Health Centers (CMHCs). Certain hospitals in Maryland that are paid under Maryland waiver provisions are also excluded from payment under OPPS.

Outpatient file Hospital Outpatient Prospective Payment System (OPPS) file Hospital Outpatient Prospective Payment System (OPPS) Partial Hospitalization Program
Population included Includes all fee-for-service (FFS) beneficiary Part B institutional claims submitted through the 837I electronic form or on a UB-04 paper form. These include hospital outpatient, renal dialysis, community mental health centers, and other Part B services provided by hospitals, skilled nursing facilities, and home health agencies. Subset of LDS Outpatient file: Includes claims that were paid under the Outpatient Prospective Payment System (OPPS). Subset of LDS Outpatient file: Includes claims that were paid under the OPPS Partial Hospitalization program from Community Mental Health Centers (CMHC).
Approximate # of claims included the 2015 file 152,900,000[1] 86,700,000[2] 79,000[3]
Variables included Includes the maximum number of claims variables available to researchers. See the Outpatient record layout for variable list. Subset of LDS Outpatient file variables: Includes variables that relate to the facility, service, and payment. See the OPPS record layout for the variable list. Subset of LDS Outpatient file variables: Includes variables that relate to the facility, service, and payment. See the OPPS Partial Hospitalization record layout for the variable list.
Can the beneficiaries and facilities be linked to other LDS claims or enrollment files? Yes, both beneficiary identifiers and facility identifiers are linkable to other LDS claims and enrollment files. Beneficiary: DESY_SORT_KEY Facility: ORGNPINM PROVIDER (also known as the CCN) Facility identifiers only: PROVIDER-NUMBER (also known as the CCN) Facility identifiers only: PROVIDER-NUMBER (also known as the CCN)
Table 1. Comparison of three LDS outpatient files
Appendix

 


[1] Medicare CY 2017 Outpatient Prospective Payment System (OPPS) Proposed Rule Claims Accounting. (n.d.). Retrieved January 27, 2017, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-P-OPPS-Claims-Accounting.pdf

[2] See footnote #1

[3] Medicare Hospital Outpatient Prospective Payment System (OPPS) Partial Hospitalization Program LDS file page. Retrieved January 31, 2017, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/HospitalOPPSPHPLDS.html

For more information about the Outpatient Hospital Claims Processing go to the Medicare Claims Processing Manual, Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS).