Check with your payer on multiple-procedure cases
Question: What about patients who require additional services during the same encounter? Do their claims require special handling under APGs?
Answer: Many ambulatory services fall under the category of elective rather than acute care. But those lines are blurring as more services shift from the inpatient to the outpatient sector.
If a patient has to undergo a higher level of treatment, usually the CPT-4 Manual will make allowances by designating a higher-level CPT-4 code for the procedure. The significant procedure code assigned to the claim should therefore reflect that higher level of service.
For example, if a patient who undergoes an exploratory laparotomy (CPT-4 49000) requires drainage of an abscess, the significant procedure would be coded at the higher CPT-4 49020.
The 3M Health Information Systems, Version 2.0 APGs is designed to consider only what is regarded as a significant procedure or principal diagnosis in a visit. Unless a payer has provided for secondary, unrelated procedures during the same patient visit, it may not pay for the additional services.
There may be time frame issues that alter these situations. A patient encounter may be defined as limited to one day by one payer or three days by another. Conceivably, two procedures can be performed on two consecutive days and billed separately in the first scenario but not in the second.
Therefore, when negotiating your APG contract, determine whether the health plan has special provisions for secondary diagnoses or separate procedures. It may be that these cases can be assigned additional APGs, which would mean a higher total payment. Or the payer may have a carveout provision set aside, which may pay separate rates for the additional services.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content