Health Information Management

Q&A: Are we coding and billing Comprehensive APCs correctly?

APCs Insider, February 6, 2015

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Q: We don’t quite understand the CMS' new Comprehensive APCs (C-APC) and how to code or bill for the services. We want to be sure that we do this correctly so we receive the appropriate payment for services.
A: Comprehensive APCs are just what the name implies–the APC provides a comprehensive payment for the full realm of services provided. This is the next step in the packaging plan that the OPPS has always been based upon–providing a prospective payment for services provided to an outpatient.
C-APCs build on the packaging that is already in place. Last year, we saw the laboratory services packaged into procedures provided on the same date of service. For 2015, CMS is providing a payment based on the services reported on a single claim. This methodology applies to device-intensive APCs for 2015.
CMS has instructed hospital providers to continue to charge and code based on the services provided; they do not have to do anything differently. The OCE and the PRICER logic for 2015 provides automatic assignment of a C-APC payment when there is a code on the claim with status indicator J1. New for 2015, J1 triggers the OCE and PRICER to provide a single payment for the primary service and all adjunctive services reported on the same claim. 
Providers should ensure that all services provided are charged and coded correctly as CMS will continue to use claims data for future rate setting. If providers stop reporting services because they don’t receive additional payment, the industry will see a decline in payments in future years.
Your clinical and ancillary staff must understand that they should report services as they always have–that is still of utmost importance. In addition, providers should do their due diligence and ensure that the payments are correct for these C-APCs, as this is new territory under the OPPS.
Providers should review the payments against Addendum B and Addendum J of the 2015 OPPS final rule to ensure that payments are appropriate for the services reported. CMS has updated the Medicare Claims Processing Manual, chapter 4, by adding a new section (10.2.3) and revising an additional section (10.4) to reflect payment policies related to C-APCs.
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.

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