Comprehensive APCs: 4 Steps for Review

It’s already two months into 2015 and I can’t help but think of the changes coming to the outpatient prospective payment system (OPPS) and APCs. CMS introduced APCs and OPPS in 2000. Since then, they have been working to slowly increase packaging within the system.

In 2014, significant increases in packaging were introduced. This year, they have continued to make major changes that will have an impact on every hospital that is subject to the Medicare OPPS and APCs. I am specifically thinking about:

• Comprehensive APCs
• Dramatic increase in conditionally packaged HCPCS codes (status indicator Q1)

I spoke about both of these in a webinar on December 30, 2014, and I would like to comment a little more about comprehensive APCs. I think they are going to impact all those who perform these services.

Comprehensive APCs (C-APCs)

CMS has introduced a specific set of logic for assigning and paying for C-APCs. Every facility should do a review of the revenue impact this change will make. Every facility needs to make certain they have someone who knows and understands the logic for assigning C-APCs and the resulting payment, as it will help you analyze what the overall impact will be.

Here is a summary of the logic and some general thoughts to consider when reviewing C-APCs for your facility. There are four basic steps when looking at a claim with a C-APC. Remember these are APCs with a J1 status indicator, newly introduced this year. The steps are:

1. Identify the payable C-APC (only one is payable, even if there are several codes that might be initially assigned a J1 status indicator)

2. Look for a complexity adjustment. Review the table for complexity adjustment to determine if that code pair is present and, if it is, whether the secondary HCPCS is ranked higher. If it is, the primary service is still assigned the complexity APC and the secondary is packaged, otherwise the primary procedure is assigned the C-APC.

3. Identify any services (by CPT/HCPCS code) that might be exempt from packaging

4. Package all other services on the claim – no separate payment for them

Some key thoughts to keep in mind:

C-APCs are a bit different than normal APC grouping logic because they apply to the whole claim. They are not date-of-service based, like many edits, MUEs and inpatient only processing. They are not line item based like most APC assignments and packaging. Because they apply to the whole claim, it is important to consider what is on that claim. Is this perhaps a series bill, or is this a group of services that are related and therefore billed together?

Consider an implantation of an AICD. If the workup is done on a Monday and the device is implanted on a Thursday, how does one want to bill that, as a single claim or as two separate claims? If billed as a single claim, all the services provided during the workup will be packaged, even if a L1 modifier is appended to the lab services. If billed as two separate claims, the services provided during the workup could be paid separately, and the C-APC representing the implantation of the AICD would be paid. Of course, anything else provided on the date of the implantation would still be packaged.

Now consider a series bill, such as stereotactic body radiation therapy, that may be provided in multiple sessions over the course several days. If these are billed on a single claim, one episode will be paid and all other episodes will be packaged. It may not ever receive a complexity adjustment. (Please note that other services might receive a complexity adjustment). If each episode is billed individually, each claim will be treated individually with an outcome where each episode will likely be assigned a C-APC and paid separately.

I am not saying one way is better than another. I am saying that each facility needs to do their analysis and answer that question for themselves. What may seem logical and obvious may not be once the numbers are reviewed including any costs for process and system changes.

If your review is manual, don’t try to look at everything, rather look at those services that are most common or have the largest financial impact. Maybe pick the 3-5 C-APCs with the largest impact. With that done, you can extrapolate to the organization. Do your homework and good luck!

Dave Fee is content manager, applied research with 3M Health Information Systems.

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