Health Information Management

Tip: Understanding CMS’ Comprehensive APCs

APCs Insider, August 29, 2014

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CMS reintroduced Comprehensive APCs for device-dependent APCs with additional refinements in the 2015 OPPS proposed rule. CMS initially finalized the concept in the 2014 OPPS final rule. Using Comprehensive APCs, CMS will make a single payment rather than separate, individual APC payments for certain procedures and add-on codes.
 
The 2015 OPPS proposed rule now includes some lower-cost device-dependent APCs and two new APCs for other procedures and technologies that are either largely device dependent or represent single-session services with multiple components. CMS is now proposing 28 Comprehensive APCs for 2015, after consolidations and refinements based on more current data and provider commentary to last year's rules.
 
The most significant change to the policy is a proposed "complexity adjustment." The adjustment is applied when a primary procedure assigned to a Comprehensive APC is reported with other specified procedures also assigned to Comprehensive APCs or with a specified packaged add-on code. When the facility reports one of these combinations, CMS will increase the payable APC to the next higher APC in the clinical group, similar to DRGs on the inpatient side.
 
In Addendum J of the proposed rule, CMS provides a breakdown of cost statistics for each code combination that would qualify for a complexity adjustment, including primary code and add-on code combinations.
 
This tip is adapted from “CMS reintroduces Comprehensive APCs along with complexity adjustments” in the September issue of Briefings on APCs.



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