Outpatient Prospective Payment System (OPPS) Project

Outpatient Prospective Payment System (OPPS) Project

Understanding Ambulatory Payment Classification (APC)

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Purpose and Objectives

After this presentation, you will have a better understanding of OPPS and the tools you will need to bill successfully.

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Agenda

? Key Terms ? How APC pricing works ? Coding, Billing and Edits ? Claim walk-through ? Changes to the Remittance Advice ? Resources ? Wrap-up

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Key Terms

? APC (Ambulatory Payment Classification)

? OPPS is more commonly known by its grouping methodology, Ambulatory Payment Classifications, or APCs.

? An APC is assigned to each CPT/HCPCS code that represents a service paid under OPPS.

? APCs are applied to the full range of ambulatory services, including same day surgery, hospital ER and outpatient clinics.

? Each APC has a pre-established prospective payment amount associated with it. In essence, APCs are a line-level fee schedule by procedure code.

? The APC assigned to each CPT/HCPCS may be found on the new APC-based fee schedule, which will be posted to the EqualityCare website.

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Key Terms

? Outpatient Code Editor (OCE)

The OCE software was developed for the implementation of the Medicare OPPS. The two main functions of the OCE are to identify errors and assign APCs. In addition, the software performs the following functions when processing a claim:

? Edits a claim for accuracy ? Assigns status indicators ? Determines if packaging is applicable ? Applies discount factors, if applicable

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