Here are key points to know about APCs
At press time, ambulatory patient classifications (APCs) were to be implemented in hospital-based outpatient settings on July 1, 2000. Here are key points to be aware of, according to Candace E. Shaeffer, RN, MBA, vice president of coding/quality management for Lynx Medical Systems, a Bellevue, WA-based consulting firm that specializes in coding and reimbursement for EDs:
• APC reimbursement includes only the facility portion of the ED visit.
• APCs do not affect physician payment. Physicians will continue to be reimbursed using the Medicare physician fee schedule.
• Initially, APCs will only apply to reimbursement for Medicare patients. Other government payers and commercial payers might follow.
• APCs include medical visit APCs and procedure APCs. If both visit and procedure services are provided and documented during a single ED encounter, both will be paid.
• In general, APC payment will be determined by multiplying the APC weight by a conversion factor. Payment will be indexed for location. Minimum and maximum patient copayments have been established by the Health Care Financing Administration (HCFA).
You won’t use ICD-9-CM codes for payment
• The hospital coders will assign common procedural terminology (CPT) visit and procedure codes based on the ED nurses’ and physicians’ documentation or convert the nurse-identified visit level and procedures (on a charge ticket for example) to CPT codes. The CPT codes (and International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes) will be submitted to Medicare for payment. ICD-9-CM codes won’t be used to determine payment for the ED medical visit as suggested in the proposed APC rule in September 1998.
• There are 451 APCs listed in the final rule: 290 medical visit and procedure APCs and 161 pharmaceutical, blood product, or other medical product APCs. There are four visit APCs in the ED: 610, 611, 612, and critical care, 620. In addition, most of the surgical, nursing, and diagnostic procedures performed in the ED — by nurses or physicians — have a corresponding CPT code and APC reimbursement. Examples of such procedures include laceration repair, fracture care, 12 lead ECG, 3 lead monitor, splinting, and intramuscular or intravenous injections.
• Under APCs, most supplies and pharmaceuticals will be "bundled" in to the visit or procedure and will not be paid separately.
• An ED’s facility coding methodology and Chargemaster will need to be revised to incorporate procedures if they are not already included. Review a copy of the final regulation, published in the April 7, 2000, Federal Register, to determine each procedure that is performed in a particular ED that also has a corresponding APC value. (See Resource, above, for information on obtaining a copy of the regulations.)
Be consistent with charging system
• HCFA has said that an ED does not need to change its particular "level of service" coding methodology, but it does need to have a charging system that it applies consistently. This charging system will have to be translated to the ED CPT codes, 99281-99285 and critical care 99291 in order for the ED to bill for services under APCs.
• If a patient is transferred from the ED to observation, the ED visit CPT code will be assigned along with codes for any procedures performed in either setting. There will be no separate "visit" reimbursement for the observation stay.
• Expert outpatient coders will be required to perform the ED coding function. In addition to the need to assign CPT codes, HCFA has identified specific modifiers that will be required in the code assignment process, and the correct coding initiative (CCI) edits will apply.
CCI is a program that HCFA implemented in January 1996. The goal was to identify and eliminate the incorrect coding of medical services. To accomplish this goal, HCFA installed "edits" in their claims processing systems to catch potential code combination problems. The two main edits are comprehensive and component code combinations and mutually exclusive code combinations. The rules for these edits come from CPT definitions and Medicare carrier instructions.
• If a Medicare patient is seen in the ED and admitted to the hospital, a separate APC or APCs will not be paid. The ED visit is rolled into the inpatient stay, and the hospital is reimbursed under the inpatient DRG payment system.
The new hospital outpatient prospective payment system regulations, including the complete list of procedures that may be billed separately, are published in the April 7, 2000, Federal Register. The regulations are available from the Federal Register’s on-line database through GPO Access, a service of the U.S. Government Printing Office (www.access.gpo.gov/su_docs/aces/aces140.html). The regulations also can be downloaded from the Health Care Financing Association’s Web site at www.hcfa.gov. Also, the Federal Register is available at many libraries. Or for copies, send your request to:
• New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. The cost of each copy is $8. Specify the date of the issue and enclose a check or money order payable to the Superintendent of Documents, or your Visa or MasterCard number and expiration date. Credit card orders also may be placed by calling the order desk at (202) 512-1800 or by faxing them to (202) 512-2250.
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