Ambulatory Payment Classification System Flashcards

Questions and Answers

What is the unit of payment under the OPPS?

the APC (Ambulatory Payment Classification)

What does the Ambulatory Payment Classification (APC) system organize?

HCPCS Level I CPT® and HCPCS Level II codes into groups called ambulatory payment classifications

What is assigned to each HCPCS Level I (CPT) code under the Ambulatory Payment Classification System?

a payment status indicator (PSI)

What does payment status indicator N indicate?

items and services that are packaged into APC rates Signup and view all the answers

How many payment status indicators are there?

26 Signup and view all the answers

Match the following status indicators with their descriptions:

A = Services paid under a fee schedule or payment system other than OPPS B = Codes not recognized by OPPS when submitted on outpatient hospital bills C = Inpatient Procedures D = Discontinued Codes E1 = Items not covered by Medicare outpatient benefit category E2 = Items for which pricing information is not available F = Corneal Tissue Acquisition and some CRNA Services G = Pass-Through Drugs and Biologicals H = Pass-Through Device Categories J1 = Hospital Part B Services Paid Through a Comprehensive APC J2 = Hospital Part B Services That May Be Paid Through a Comprehensive APC Signup and view all the answers

What does status indicator E1 represent?

Items and services not covered by any Medicare outpatient benefit category Signup and view all the answers

Which status indicator is assigned to nonpass-through drugs and nonimplantable biologicals?

K Signup and view all the answers

What is represented by status indicator M?

Items and services not billable to the MAC Signup and view all the answers

Which status indicator indicates items and services packaged into APC rates?

N Signup and view all the answers

What is the meaning of status indicator P?

Partial Hospitalization Signup and view all the answers

What does status indicator Q4 signify?

Conditionally Packaged Laboratory Tests Signup and view all the answers

What does status indicator T represent?

Procedure or Service, Multiple Procedure Reduction Applies Signup and view all the answers

Study Notes

Ambulatory Payment Classification System Overview

The primary unit of payment under the Outpatient Prospective Payment System (OPPS) is the Ambulatory Payment Classification (APC).
The APC system categorizes outpatient services into groups linked to specific HCPCS Level I (CPT) and HCPCS Level II codes to determine reimbursement by Medicare.

Structure of the APC System

APCs consist of several hundred groups that determine payments for various outpatient hospital services.
Some services, such as anesthesia and minor ancillary services, are considered packaged within the APC payment and are not reimbursed separately.
Each CPT/HCPCS Level II code is designated to one APC, and the assignment remains constant regardless of the patient's diagnosis.

Payment Status Indicators (PSI)

Each HCPCS Level I (CPT) and Level II code, as well as APCs, is assigned a Payment Status Indicator (PSI) under the APC system.
PSIs are essential in determining payment eligibility for services under OPPS.

Types of Payment Status Indicators

A: Services paid under other fee schedules (e.g., ambulance services, therapy).
B: Codes not recognized by OPPS on outpatient bills.
C: Inpatient procedures.
D: Discontinued codes.
E1: Non-covered items, excluded by Medicare.
E2: Services lacking pricing data.
F: Corneal tissue acquisition and certain CRNA services.
G: Pass-Through Drugs and Biologicals.
H: Pass-Through Device Categories.
J1/J2: Hospital Part B services regarding APC payment.
K: Nonpass-Through Drugs, including non-implantable biologicals.
L: Influenza and pneumococcal vaccines.
M: Services not billable to the Medicare Administrative Contractor (MAC).
N: Services packaged into APC rates.
P: Partial hospitalization.
Q1/Q2: Specific packaged codes.
Q3: Codes potentially payable through Composite APC.
Q4: Conditionally packaged laboratory tests.
R: Blood and blood products.
S: Services not discounted when multiple services performed.
T: Procedures with multiple discounts applied.
U: Brachytherapy sources.
V: Clinic or emergency department visits.
Y: Non-implantable durable medical equipment.

Conclusion

The Ambulatory Payment Classification System is a fundamental mechanism for determining Medicare reimbursement for outpatient services, with essential roles played by APCs and PSIs. Understanding the classifications and their implications is crucial for effective billing and compliance in healthcare.

Description

Test your knowledge with these flashcards on the Ambulatory Payment Classification (APC) system. This quiz covers key terms and definitions related to outpatient services coding and reimbursement, helping you understand APC organization and structure.