Health Information Management

Comprehensive APCs represent a major shift in OPPS policy

APCs Insider, November 14, 2014

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By Steven Andrews, Editor
CMS’ finalization of its comprehensive APC (C-APC) policy represents the most radical change finalized in the 2015 OPPS final rule. C-APCS introduce an inpatient-like complexity adjustment for outpatient hospital services.
The policy will be implemented January 1, 2015, with 25 C-APCs and CMS plans to create more in subsequent years. This continues CMS' stated goal of bundling more services to give hospitals "improved incentives to provide efficient and high quality care at lower cost."
CMS identified certain high-cost, typically device-related outpatient procedures to serve as the primary service for C-APCs, listed in Addendum J of the final rule. CMS will provide separate payment for these services and will package all other services reported on the same claim, with some exceptions. 
The CPT® codes that are part of the C-APC logic are assigned status indicator J1, and when a J1 service is reported on a claim, CMS will pay for it. CMS will consider most other items and services on the claim adjunctive, supportive, related, or dependent.
These items and services will be packaged in 2015, even though they currently generate separate payment, according to Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota.
Excluded items and services include:
  • Preventive services
  • Pass-through drugs, biologicals and devices
  • Brachytherapy seeds and sources
  • Cost-based services such as vaccines
CMS also excludes services paid on other fee schedules, including ambulance services; mammography services; and therapy provided under a plan of care and reported on a separate monthly claim.
CMS finalized a policy to recognize more complex cases and to pay for them accordingly using a complexity adjustment, such as when two J1 procedures are reported on the same claim. 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.
The C-APC policy does not account for providers who use claims that span multiple days, according to Shah. Providers will have to assess the impact of these changes, since many services unrelated to the C-APC procedure may be included on the claim and packaged regardless.
For highlights of other policies finalized in the rule, see For more analysis on the changes in the 2015 OPPS final rule and how to implement them, join Shah and Valerie A. Rinkle, MPA, at 1 p.m. (Eastern) on Tuesday, December 9, for HCPro's 12th annual OPPS final rule webcast.



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