Health Information Management

Top APCs are too facility-specific to predict

APCs Insider, February 25, 2003

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February 21, 2003
Vol. 4, No. 7

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A sneeze can travel at speeds exceeding how many MPH?

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The bacteriologist and his discovery was ALEXANDER FLEMING AND PENICILLIN.

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We've got terrific resources for your APC coding team. Check out our two APC newsletters.

"Briefings on APCs" is a monthly newsletter devoted entirely to managing under APCs, including tips, charts, and advice from the experts.

"APC Answer Letter" is a question and answer publication - readers supply the questions, our experts supply the answers. Click on the links to find out more.




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Keith Siddel,
MBA, PhD (c),
president, CEO
HRM, Hospital Resource Management

Cheryl D'Amato,
director health information management
HSS, Inc.

Julie Downey,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,
professional services consultant
Precyse Solutions

Julia R. Palmer
Health Information Management Division of HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System





Improve the bottom line: conduct APC audits

Conducting an APC audit identifies your problem billing areas, allowing you the opportunity to fix them and ultimately improving your facility's revenue.

And that is nothing to sneeze at.

Auditors should conduct audits throughout the year, to ensure that the organization's procedures to assess and address issues of accuracy are working.

Your audit should take into account coding and claim development laws, policies affecting outpatient coding, and APC reimbursement losses from improper or missing documentation.

To streamline your audit, consider these four tips offered by Janet Kucinski, RHIA, CCS, CCS-P and Julia Palmer, MBA, RHIA, CCS:

  • Perform an internal audit of records from all outpatient departments. Include records from the ED, cardiac catheterization, GI lab, and interventional radiology.

  • Determine the costs, benefits, and revenues in coding departments. Is it more cost effective to have the ancillary department, or your HIM department handle coding?

  • Document any differences between the APC reimbursement your facility received and the amount the audit revealed to support compliance activity changes.
  • Develop a matrix of all outpatient service areas to be certain it's clear who has responsibilities for applying both diagnosis and procedure codes. Double check your facility's accuracy through frequent audits—this will help you reevaluate your current APC processes, and it will save you money!
Check out the March issue of Briefings on APCs for more on audits and to keep up to date on all the changes presented in recent program memos, including hepatitis B codes and new G-codes, and tips on correctly using modifiers.

Your "APCs Weekly Monitor," is a free weekly e-zine from HCPro, publisher of "Briefings on APCs," the monthly newsletter devoted entirely to managing under APCs, and the newsletter, "APC Answer Letter," with answers to readers' questions about coding for APCs.

The "Monitor" is a complimentary companion publication, with a specific mission: to provide answers to your tough questions about the APC regulations.

If you have a question about APC coding that you would like addressed in the "Monitor," post it on our Web site at Each week, our team of experts answers questions that will appeal to the majority of readers. The elected questions and their corresponding answers are delivered to your inbox every Friday.

Top APCs are too facility-specific to predict


I work in a physical rehabilitation hospital. A patient was admitted to our facility due to mechanical complication of his hip replacement, and had a revision of the hip replacement.

What ICD-9-CM code would be appropriate for the revision, using only diagnosis codes (not the procedure code or CPT code)? Would the revision still be coded as V43.64, hip-replacement status?


Critical care coding and compliance concerns

As the source of the highest-paying evaluation and management (E/M) codes, you can bet all eyes are on accurate coding and documentation for critical care services.

Several issues can cause confusion over when to use these codes. For example, critical care is a type of service, not a place of service.

"One of the big mistakes that doctors make is, when they have a patient in the critical care unit, they want to bill a critical care visit," says Jo Ann Steigerwald, RHIT, senior consultant with the Wellington Group in Cleveland.

"But critical care by CPT definition means the patient is in pretty severe trouble. The physician has to be responding to specific types of events and providing the services detailed in the CPT description of 'critical care' to use these codes."

Click here to read more. The cost is $10.

Medical Records Briefing subscribers have free access via their online subscriptions.


Do you have access to the TOP 30 APCs being used? Can you direct me to a site where this information may be obtained?


The short answer is no. There is no way to identify the top 30 APCs that would apply to all facilities. Volume data is specific to each facility, and dependent on many variables, such as the types of services, and the patient population. The only way to find the top APCs for your organization is to run reports that compare the data from the past year and the current year to look for changes or trends.

The long answer is there are places to look to find similar information. One of our experts found top 10 APCs information for Massachusetts on the Massachusetts Health Data Consortium Web site under "Free Data." Perhaps there are similar sources in other areas.

Theoretically, there are other ways to get volume data for payer-specific patients. For example, Medicare collects data on all of the claims submitted for payment. All of the APCs would be available in the Medicare Outpatient Analytical File.

However, there are two caveats: Medicare sells the data and it can be expensive, and the data is typically at least a year old by the time it is released. This means that the most recent data available would be from the last quarter 2001. Some insurance companies collect this data as well, but seldom make it available.

Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.



Getting the diagnosis right is key to getting paid. There is help available to get a handle on more than 160 new diagnosis codes and their proper use.

Attend a live audioconference, "The New ICD-9 Diagnosis Codes: Understanding the Changes and their Use" on February 26. Get your questions answered in real time following the presentation. For more information or to register, CLICK HERE, or call our customer service department at 800-650-6787. Be sure to mention source code EZ8282C.


Do you understand the new reimbursement opportunities for APC observation services?

A new year always spells APC and OPPS changes, and 2003 brings you new ways to code and bill observation services for APC reimbursement. Are you getting every appropriate dollar for the work you do?

Learn what you need to know during a 90-minute live audioconference, "Observation Services and APC Payments: Key Coding and Billing Changes for 2003" on Thursday, March 12, beginning at 1 p.m. Eastern.

For more information or to register, CLICK HERE, or, call our customer service department at 800-650-6787. Be sure to mention source code EZ8499B

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