Apc Grouper Edits

Maria Johnson
• Tuesday, 21 September, 2021
• 9 min read

This version of the One processes claims consisting of multiple days of service. Assign an Ambulatory Payment Classification (APC) number for each service covered under Opus, and return information to be used as input to a PRICER program.

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Assign an Ambulatory Surgical Center (ASC) payment group for services on claims from certain Noncoms hospitals. It is the user's responsibility to organize all applicable services into a single claim record, and pass them as a unit to the One.

The One software is responsible for ordering line items by date of service. In order to accommodate this functionality, the One is structured to return lists of edit numbers.

Since these coding systems are complex and annually updated, the centralization of the direct reference to these codes and modifiers in a single program will reduce effort and reduce the chance of inconsistent processing. This integration does not change current logic that is applied to outpatient bill types that already pass through the Opus One software.

However, with the integrated One, line items on claims from noncoms hospitals will be assigned specific edit numbers and dispositions, where in the past; this type of detail was not provided. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association.

| Terms of Use | Privacy Policy | Standards of Business Conduct ... Grouper with One Edits HOME COMPANY OVERVIEW SOLUTIONS OVERVIEW Claim shop/CONTRACT MODELING STRATEGIC CONTRACTING GROUPERS & Prices FAQ & TOOLS EVENTS CONTACT US APC Groupers and Prices Grouper WITH One EDITS APC / Grouper is the most comprehensive ambulatory grouper available and is part of a family of state ... Is training available for my STA... Claim shop/Contract Modeling HOME COMPANY OVERVIEW SOLUTIONS OVERVIEW Claim shop/CONTRACT MODELING STRATEGIC CONTRACTING GROUPERS & Prices FAQ & TOOLS EVENTS CONTACT US Claim shop/Contract Modeling Claims Repricing To achieve the highest level of efficiency and accuracy, mayors must eliminate as many manual processes as ...

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Organizations can purchase this software independently or as part of a full integration with the Described Computer Assisted Coding (CAC) solution. The new EM scribe Encoder offers immediate access and analysis to DRG and APC reimbursement data.

In addition, the EM scribe Encoder allows users to reference and search for all the codes and terms that support the final steps before billing. Once the codes are generated for MS-DRG, APR-DRG, and APC, coders can use the grouper function to include reference materials used by coders and revenue specialists such as AHA coding clinic, CPT assistant, Medicare edits, etc.

AMI’s Described Encoder is the most cost effective, it provides unrivaled accuracy, is easiest to use, boasts the greatest functionality, and is Vendor Agnostic. We strive to solve complex problems with modern solutions that are cost effective and efficient.

The initial variable used in the classification process is the diagnosis for Dogs and the procedure for APC's. The APC classification system is designed to explain the amount and type of resources utilized in an outpatient visit.

Each APC consists of patients with similar clinical characteristics and resource usage. APC's include only the facility component of the visit; medical professionals will continue to be paid from a fee schedule based on CPT-4 procedure codes and modifiers.

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The system encompasses all provider-based ambulatory settings including same day surgery centers (Asks), emergency departments (ED), and clinics, but excludes home visits, nursing home or inpatient admissions. Examples of surgical APC's include cataract removal, endoscopies, and biopsies.

Examples of significant procedure APC's are psychotherapy, CT and MRI scans, radiation therapy, chemotherapy administration, and partial hospitalization. • Medical APC's consist of encounters with a health care professional for evaluation and management services.

The medical APC is determined based on the site of service (clinic or emergency department) and the level of the evaluation and management service (low, mid, or high), as indicated by the evaluation and management CPT-4 code and the diagnosis. Examples of ancillary APC's are plain film X-rays, electrocardiogram, and cardiac rehabilitation.

Effective last January, providers are required to report modifiers, if appropriate, for outpatient services on the UB-92 billing form. Modifiers are being required for outpatient services in preparation for the introduction of Correct Coding Initiative (CCI) edits.

Modifiers will be needed to prevent the CCI edits from rejecting pairs of CPT codes that would not normally be reported on the same UB-92. Please refer to the 1999 AMA CPT Coding manual for an explanation of the modifiers and those that can be used for hospital outpatient visits.

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Modifier 74 is used if the procedure is terminated after anesthesia is administered and is paid the full APC amount. Modifier 25 is applied to an Elm code to indicate that a surgical procedure performed during the visit was a direct result of the evaluation and management service.

Another notable coding change includes the ability to bill for critical care (CPT 99291) for the evaluation and management of an unstable critically ill or injured patient who requires the constant attendance of a physician. Additionally, a new Hopes code will be created for reporting screening services performed in the ED when no medical emergency exists and the patient is referred to a clinic or physician's office for treatment.

This screening APC would be paid only if no other emergency services were rendered, and includes any consults. For example, if you currently bill a month's worth of radiation therapy treatments utilizing the form/through dates on the UB-92 with the number of units indicating the number of treatments given during the period, you will now need a separate line item for each date of service.

Multiple clinic visits on the same day for different diagnoses should be submitted on separate claims. There is also a proposal to modify the UB-92 to identify diagnoses by number and link them to the individual line item being billed, similar to the HCFA-1500.

The outpatient claims editor will be expanded to include a subset of the CCI edits. Unbundled codes will be eliminated from the claim prior to APC assignment and payment.

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Anesthesia, medical, and surgical supplies, drugs (except chemotherapy), blood, Ions, casts, splints, and donor tissue will also be packaged into the APC. These services should be continued to be reported so that when the weights are recalculated, the data utilized by CFA will include all the appropriate costs.

Multiple surgical procedures performed during the same operative session will be discounted by 50%, just as they currently are under the ASC payment mechanism. Weights and rates for APC's were based on 1996 Medicare claims and the most recent settled cost report for each facility.

However, the proposed system does not provide adjustments for outliers or teaching, rural, disproportionate share, Terra or specialty hospitals. The co-payment will initially be set at 20% of the 1996 national median APC charge after standardizing for wage variation and then will be updated to 1999.

The co-payments are frozen at the 1999 level until the Medicare payment percentage reaches 80% of the APC rate. Hospitals will be allowed to discount their co-payment amount in an effort to generate competition between providers.

Hospitals will experience increased financial risk due to the lack of a phase-in, very limited payment adjustments, and volume control induced reductions to future rates. PPS will also affect hospital operations, particularly the registration, coding, and billing processes and the information systems that support them.

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Outpatient data access, availability, and quality is problematic for many hospitals due to the volume of visits and information systems limitations. Additionally, management and reporting processes based on APC's will need to be developed.

Compliance issues may result if monitoring and control procedures are not carefully implemented and followed. The billing challenges include multiple visits on the same day, line item identification of recurring services, clarification of provider-based status, APC grouper errors, lack of pre-fill edit capability, handling of late charges, and reconciliation of billed vs. paid amounts, to name a few.

The operational challenges include the ability to distinguish whether multiple visits on the same date of service are related to the same diagnosis or different diagnoses. Documenting all procedures performed in the ED, clinics, and treatment/procedure rooms, identifying those that are the direct result of a medical visit and selecting the appropriate modifier will require training.

The systems challenge include retaining historical data in a readily available format, integrating the APC grouper, enhancing the pre-fill edit process, identifying multiple visits on the same date, splitting out recurring visits by date of service, establishing and maintaining data integrity across system interfaces, standardizing the hospital's CDM across departmental systems, and developing a management reporting capability. They will also need to review the CDM, super bills, and data entry screens to ensure that appropriate codes are assigned.

• Education of administrative, departmental, clinic and medical staffs will be essential to complete the first two prerequisites. This will require improvements to data access and retention as well as reporting and analysis capabilities.

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While hospitals have learned to survive and thrive under Dogs, success did not happen overnight. It is a division of Global, a worldwide provider of business and information technology services.

When 3M business partners subscribe to 3M Grouper Plus Content Services (GPS), 3M experts do the heavy lifting to maintain and update complex and dynamic regulatory information. You can also reduce IT expenditures, because there’s no local software installation or the need to modify interfaces when new content is received.

This very popular solution is used by providers, payers, fiscal intermediaries, and state and federal agencies. It can operate in batch mode (to process high volumes of claims data) or in “interactive mode” (to let you enter, modify, and process individual claims and review the output from the grouping and reimbursement calculation).

The 3M Clinical Risk Grouping Software is a grouper that measures an individual’s chronic illness burden using inpatient, ambulatory, and pharmacy data over a period of time and provides the basis for predicting future use of medical services. Managed care organizations, researchers, consultants, epidemiologists, and government health policy leaders can all use the 3M Clinical Risk Grouping Software to group patient data as the basis for evaluating patient populations for effective risk adjustment, managing resources for delivering care, defining episodes and projecting future costs of care.

Uses administrative claims data (including the present on admission, or POA, indicator) to identify PCs and CMS Has Requires no clinical abstracting from patient charts or manual gathering of clinical information Leverages the 3M™ APR DRG Classification System to cover all patients for more comprehensive and precise analysis This 3M-proprietary methodology addresses all population groups to better reflect current clinical care complexities, practices, and cost structures for outpatient services.

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Creating a common system for what can be competing care settings Provides a methodology for equitable reimbursement Does not rely on a series of fee schedules, simplifying implementation and ongoing support, as well as providing better financial management than APC's Today, 3M supports grouping, editing, and reimbursement configurations for over 50 federal, state, and commercial payer and reporting organizations implemented for payment, quality and public reporting and also provides access to reimbursement calculations for federal, state, and commercial payers.

The 3M Inpatient and Outpatient Payment Calculation Toolkits allow payer and provider clients to calculate expected reimbursement for hospital inpatient and outpatient payment methodologies that are not supported within the 3M Core Grouping Software, the 3M Grouper Plus System, or equivalent mainframe solutions. Though this reimbursement scheme does not use grouping, you should set up your schedule to use the One/ APC grouper to ensure you receive the appropriate edits.

The system is available as a Microsoft® Windows® application or a web-based edition and also offers a wide selection of groupers and reimbursement formulas to support many federal and state payment and quality initiatives.

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