The ability to access any university’s resources through Course Hero proved invaluable in my case. 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. 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. 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. 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. Additionally, the discount cannot be less than 20% of the APC payment rate and the co-payment reduction cannot be written off or the deductibles waived.
PPS will also affect hospital operations, particularly the registration, coding, and billing processes and the information systems that support them. 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. While hospitals have learned to survive and thrive under Dogs, success did not happen overnight.
Mod 1 Quiz 1Question 1An Grouper is used for inpatient coding. SelectedAnswer:FalseAnswers:TrueFalseQuestion 2The system used to standardize medical terminology is calledSelectedAnswer:SNOMED-CTAnswers:CAHIIMHCPCSSNOMED-CTDSM-VQuestion 3When data is extracted from chart documentation and translated into code sand then someone reviews the coding, what is the term for this process? SelectedAnswer:AbstractingAnswers: Coding DatabasingAuditingAbstractingQuestion 4Standardized terminology of patient information is created by:SelectedAnswer:SNOMED-CTAnswers:Joint Commission 3M has more than 30 years of experience developing classification, grouping and reimbursement calculation systems for inpatient, outpatient and professional settings.
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