A Guide to Ambulatory Payment Classifications

Medicare's new regulations on the Outpatient Prospective-Payment System create a radical new payment method for all outpatient care. The Outpatient PPS, with its 451 ambulatory payment classifications (APCs), requires hospitals to completely reconfigure their outpatient operations. To avoid severe financial consequences, you must elevate your coding, documentation and Charge Description Master (CDM) to a much higher level of accuracy.
HCFA says hospital Medicare payments will drop by one-half of a percent, but experts in the field see the losses as far greater if coding and documentation are not cleaned up.
The regs are out, and the July 2000 Congressional deadline for implementation is upon you, so don't procrastinate on Outpatient PPS any longer. Get "how-to" assistance from top experts on the biggest reimbursement challenge hospitals have faced since DRGs.
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The Answer Book for:

• CFOs and directors of reimbursement
• CEOs, COOs
• Directors of medical records
• Hospital compliance officers
• Directors of medical staffs
• Clinic directors
• Directors of emergency departments
• Administrators
• Directors of patient accounts, finance and reimbursement
• Directors of health information management systems

THE PRACTICAL HELP YOU NEED TODAY ... FROM TOP EXPERTS IN THE FIELD

OVERVIEW
• Purpose of the Guide • Chapter description •Resources • Summary

APC FUNDAMENTALS
• Description of APC system • Impact on hospitals• Impact on physicians • Impact on ancillary support departments • Impact on ancillary services • Impact on hospital based clinics, and other facilities • Impact on outsourced departments • APC implementation mandates • Ongoing quality monitoring of APC groups • Summary

APC CODING ISSUES
• Hospital-specific coding guidelines for HCPCS CPT and ICD-9-CM codes • Evaluation and Management (E&M) visit services • Correct assignment of modifiers • Unlisted procedures • Coding for recurring (serial) outpatients • Observation services • Partial hospitalization • Limited number of service units by HCPCS code • Upcoding watch • Annual code updates • Case mix and trend analysis •Coder review and performance management

ANCILLARY SUPPORT AREAS
• Medical necessity documentation • Chargemaster updates– codes and pricing • Charge capture process • Change of patient status from outpatient to inpatient

CHARGE DESCRIPTION MASTER (CDM)COMPLIANCE
• Chargemaster coordinator/team • Unit services • Late charges • Documentation • Significant procedures • Surgical services performed in ancillary departments • Ungroupable codes under APCs

BILLING AND REIMBURSEMENT
• Evaluation of APC reimbursement impact • Provider-based status • Inpatient-only list • Modifier reporting (codes and APC modifiers) • Multiple UB-92s for same day/unrelated visits • Outpatient window • Multiple procedures • Duplicate billing • Ancillary services • Recurring/series visit billing • Gender- specific APCs • Late charges • Service units • Medicare Outpatient Code Editor (OCE) • Correct Coding Initiative (CCI) • Clearinghouse edits • UB-92 integrity • Rebilling APC error records

INFORMATION SYSTEM ISSUES
• Online access to results (APC groupings) • Access to outpatient clinic-coded data and information • Outpatient visits abstracts • APC grouping from disparate systems • Billing systems code table maintenance • Correct coding initiative impact on all outpatient visits • Grouper installation, maintenance and training • Concurrent versus retrospective grouping • APC error reports • System storage of multiple APCs • APC standard reports and case mix analysis • Documentation of monitoring and educational efforts • Risk assessment of departmental operations • Monitoring and auditing practices, policies and procedures

TRAINING AND EDUCATION
• Hospital-wide APC education • CPT coding education • E&M policies and training • Diagnosis codes • APC grouping methodology training • Dissemination of APC policy information • Training admitting, discharge and other support departments • Resource needs

COMPLIANCE INITIATIVES
• OIG initiatives in outpatient setting • Ongoing quality monitoring • Chargemaster review • Hospital-wide Charge Description Master policy for compliance • Quality monitoring for external departments • Focused case reviews based on random sampling • Billed versus paid analysis • Solutions for problem areas • Software tools

APC MONITORING
• Development of APC strategies • APC case mix index • Reconciliation • Exception reporting • Focused studies

APPENDICES
• List of APC groups with status indicators, relative weights, payment rates and coinsurance amounts • The inpatient-only procedure codes • Payment status indicators by type of service• Drugs, biologicals and medical devices subject to transitional pass-through payment • Pertinent regulations

A Guide to APCs is by JAMES GEORGOULAKIS, Ph.D., and TED MATSON, M.A., FACHE, of the Ambulatory Care Advisory Group, Inc., a Chicago-based firm providing professional advisory, consultation, and management services exclusively for ambulatory care and emergency services. The authors were instrumental in the development of the APC regulations.

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