Health Information Management

Tip: Determining comprehensive APC reimbursement

APCs Insider, May 29, 2015

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Providers need to take multiple steps to determine the reimbursement for a comprehensive APC (C-APC) and whether a complexity adjustment will be applied if multiple applicable procedures appear on the same claim.
The first step is identifying which service will serve as the primary C-APC. The J1 procedures and codes are located in Addendum J of the 2015 OPPS final rule, and include a column called "Rank Used for Primary Assignment." When multiple J1 procedures or services appear on the same claim, the procedure with the highest rank in that category is assigned to the C-APC.
For example, a claim contains the following codes:
  • 35472, transluminal balloon angioplasty, percutaneous; aortic
  • 35475, transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel 
The first code, 35472, has a rank of 180 according to Addendum J, while 35475 has a rank of 187. As a result, 35472 is the primary service and leads to C-APC 0083 (level I endovascular procedures). Providers need to look to another tab in Addendum J to determine if a complexity adjustment applies to the claim.
This tip is adapted from “CMS releases update to correct and clarify comprehensive APC payments" in the May issue of Briefings on APCs.

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