APC - Ambulatory Payment Classifications and OPPS - Outpatient Prospective Payment System

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Watch a short YouTube movie on Ambulatory Payment Classifications with ICD10Doc.

1. Using the free text search or reverse search functions on the Home page, find an APC group that interests you and then click on the link that you'd like to continue with.





One can reach the APC group also from a CPT code that is classified in an APC group.



The APC group details include the APC number, Group Title, the pay rate under OPPS, the national and the minimum unadjusted co-pay, etc.

2. A specific CPT code may have additional classifications such as Addon code, Device Removal, Skin Substitue, Supply code, etc. that will be displayed on the CPT code page.
If interersted, with one click you can move back and forth between the APC group and the various CPT codes that are part of the group. These CPT codes are usually similar and it is worthwhile to review the nuances between them.






Background

From Wikipedia: APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. A part of the Federal Balanced Budget Act of 1997 made the Centers for Medicare and Medicaid Services create a new Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services - analogous to the Medicare prospective payment system for hospital inpatients known as Diagnosis-related group or DRGs.
This OPPS, was implemented on August 1, 2000. APCs are an outpatient prospective payment system applicable only to hospitals. Physicians are reimbursed via other methodologies for payment in the United States, such as Current Procedural Terminology or CPTs.
APC payments are made to hospitals when the Medicare outpatient is discharged from the Emergency Department or clinic or is transferred to another hospital (or other facility) which is not affiliated with the initial hospital where the patient received outpatient services.
Although APCs began through the federal system of Medicare, they have also been considered for adoption by state programs, such as Medicaid, and other third-party private health insurers.
If the patient is admitted from a hospital clinic or Emergency Department, then there is no APC payment, and Medicare will pay the hospital under inpatient Diagnosis- related group DRG methodology.

For more information on APC visit ACEP web site
For more information on OPPS visit CMS web site
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