Consider these the most common CPTs under APGs
By Dean Rossiter, MS
Senior Manager
Orion Consulting
Cleveland
Question: Which CPT-4 codes are most commonly reported when using ambulatory patient groups (APGs) and why?
Answer: The most frequently occurring CPT-4 codes include those for laboratory, chest X-ray, electrocardiograms, and evaluation and management (E&M) services. However, each outpatient facility’s experience may be different depending on factors such as clinical specialty, patient mix, and setting, whether the facility is a walk-in clinic or hospital emergency department (ED). (For examples of services in each category, see the chart, below.)
When submitting claims under APGs, remember that outpatient services are divided into three categories of APGs:
• significant procedures, including outpatient surgery;
• medical visits that involve E&M services;
• ancillary tests and procedures, which can be performed in conjunction with a significant procedure or medical visit or as the main reason for the encounter.
These categories are important because they ultimately determine how the CPT-4 codes are grouped and assigned to an APG prior to payment.
E&M codes are typically among the most frequently occurring CPT-4 codes. But under APGs, these codes are never paid separately but are used to identify medical visits, which are then assigned to an APG based on a diagnosis. The charge or cost of the E&M code is reflected in the weight given to the individual medical APG.
Ancillary services such as X-rays or blood chemistries are also commonly occurring CPT codes. But when performed in conjunction with a surgical procedure, they may get packaged, or bundled, into a significant-procedure APG depending on the pair.
As a result, the payment for the ancillary service will be lower than it would be if the ancillary service had been performed separately and was unrelated to the significant procedure. The difference will depend on the specific weights and respective pricing assigned to each APG by the payer.
The analysis of Medicare claims data (shown on p. 85) suggests that some of the most commonly reported significant-procedure CPT-4 codes under APGs also rank among the most frequently reported codes under non-APG systems.
Among the top five taken from the analysis in order of frequency are:
• physical therapy evaluation (Q0086);
• measure blood oxygen level (94760);
• cataract removal with lens insertion (66984);
• cardiac rehab/monitoring (93798);
• upper gastrointestinal endoscopy with biopsy (43239).
In comparison, the top five CPT codes based on revenue are:
• cataract removal with lens insertion (66984);
• physical therapy evaluation (Q0086);
• left-heart catheterization (93510);
• fragmenting kidney stone (50590);
• right and left heart catheterization (93526).
A glance at the comparison will immediately reveal that physical therapy and cataract surgery rank high on both lists. Even greater cross-over among certain procedures exists among the most commonly performed ancillary services.
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