Here are additional payments given by APCs
Ambulatory payment classification (APC) visit-level payments assume additional payments for physician procedures and nursing services, reports Mason Smith, MD, FACEP, president and CEO of Lynx Medical Systems, a Bellevue, WA-based consulting firm specializing in coding and reimbursement for emergency medicine. "Additional payments are associated with additional procedures," he says. Here are additional payments for ED services, according to Smith:
1. Typical ED visits at levels three and higher will include multiple line items that will materially increase the payment if reported. For example, an ankle injury evaluated in the ED and treated with either an elastic bandage or a plaster splint can have at least two services reported. The visit level is reported as 99283 (APC 611), with reimbursement set at $139. Splinting the ankle is reported 29540 (APC 058), which pays $72. The total payment is $211. Additional payment also will be made for X-rays. (See chart, below, for some of the common APC categories that apply to services routinely provided in the ED.)
2. Most of the surgical procedures (laceration repairs, fractures, and incision and drainage of an abscess) are identified by CPT code listed under an APC group with a status of "T." The full value for the highest-value service will be paid. Additional procedures within the same or other APC groups designated as status "T" will be paid at 50% of the value listed.
3. APCs identified with an "S" (significant procedures) or an "X" (ancillary services) are not subject to discount for multiple occurrences when more than one CPT code is submitted. For example, each of three intramuscular injections will be paid at the full value.
4. For visit services, Medicare will make separate payments for IV infusion therapy, intramuscular injections, and numerous other "nursing services" in addition to the level of service. Those services are not subject to discount when multiple services are performed.
5. Two new APCs were added for splinting, strapping, and casting. Those APCs include all the CPT codes listed in the splinting and strapping section of CPT.
6. Expensive drugs, such as thrombolytics, will be paid for as "add-on" payments, even if the patient is transferred and admitted to another facility.
7. Patients who die in the ED will be treated as outpatients for the purpose of payment, unless they have been admitted to inpatient status at the time of their death.
| APCs for common ED services | |||||
| APC | APC Description | Indicator Status | Medicare Payment* | Patient Co-Pay* | Total Payment* |
| 024 | Lac repair (except complex) | T | $118 | $45 | $162 |
| 043 | Closed fracture Tx | T | $80 | $16 | $105 |
| 058 | Level 1 splinting | S | $53 | $19 | $72 |
| 094 | Resuscitation and cardioversion | S | $219 | $105 | $324 |
| 359 | Injections | X | $47 | $9 | $56 |
| 340 | Minor ancillary procedure | X | $50 | $13 | $63 |
| *Numbers are rounded. T = surgical procedures. S = significant procedures. X = ancillary services. | |||||
| Source: Lynx Medical Systems, Bellevue, WA. | |||||
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