Coach Jennifer: We have someone who comes in with a question that they don’t understand how the APC signs affect coding.
Q: I do not understand how the APC indications influence coding. Naturally they affect billing and revenue, but as a coder why do I have to focus on them?
Since on one hand, there are a lot of services that are bundled and have a status indicator of ‘N’, on the other hand the course instructs to code them no matter whether they’re going to get a cost.
I would value any kind of clarification on this!
A: When we’re looking at APCs those are Ambulatory Payment Categories and those are established by Medicare and their payment rates associated with your ASCs, your ambulatory surgical. They handle the OPPS, which is I’ll enter into that in a minute or more.
The ASC, they’re not Medicare suppliers, they’re suppliers of surgical services. But they should accept Medicare and that they need to be getting involved, they should have their own private agreement with Medicare so they can be separate from a medical facility, freestanding facility or they can be connected with a health center. It utilized to be in the start when the ASCs came out, you might not be affiliated with a health center, but now they do enable hospital association.
The next thing they talk about is the OPPS. You’re going to hear … if you do any kind of billing or billing education, you hear a lot about the Potential Payment Systems. There’s Home Health Care Potential Payment System. There’s Inpatient. There’s Skilled Nursing. There are all sorts of Prospective Payment Systems out there that Medicare has developed. OPPS is the Outpatient Potential Payment System and that’s how Medicare decides how much cash a health center or mental health facility.
Outpatient still billing with Medicare, it can still be at a medical facility. That’s how much they’re going to get paid for those Medicare patients, for the outpatient services that they supplied. They appoint each HCPCS, each CPT code a letter that’s going to symbolize how it’s going to be repaid.
The status sign is an indicator that helps identify things like their policy guidelines, like “product packaging” or “bundling”. They’re paid under the Outpatient Potential Payment System but the payment is going to be a single payment, and that method there’s no separate payment for those different services. If you look up a HCPCS code or CPT code for these particular facilities that deal under the system, then if you see that N, you can say, “Well, it’s not going to be paid.
Why does a coder have to focus on that? Well, the like in a physician’s workplace you’re going to look at your NCCI modifies. You’re going to look and see, can I bill those two codes together? Are they inclusive? Do they need a modifier? Exists something I require to understand about these two? The coders are going to do the same thing in this type of system. Those status signs are going to tell you what can be submitted on that claim kind.
Medicare enjoys their formulas and when you’re dealing on the billing side, you see these solutions all the time– RVU plus the geographic index, plus this, multiple it by that. These get paid a portion when they’re dealing with the ambulatory, surgical center, or portion of that very same type of payment system, so they weight it. And then they have conversion factor which goes by your geographic locations often or the type of facility or the type of credentials they have, and that comes up with their ASC payment rate.
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