Chapter 7 Due 10/13/2021

Beginner Exercise

1. Matching (Level 1Remembering)

Match the payment status indicator on the left with the description on the right. Reference table 7.1 for a listing of payment status indicators.

Payment Status Indicator (SI)

Answer

Description

A

APC payment reimbursement methodology: included in New Technology APCs, discounted when multiple of this SI appear on same claim, same day of service

C

Comprehensive APC Payment: all services are packaged with this SI

H

Packaged payment

J1

APC payment reimbursement methodology: drugs, biologicals and radiopharmaceuticals that are not pass-through eligible

K

Conditional APC payment: STV conditionally packaged services

N

Inpatient only procedures

Q1

Conditional APC payment or via the Clinical Lab Fee Schedule when applicable

Q3

Fee schedule payment: example is physical therapy

Q4

APC payment reimbursement methodology: included in New Technology APCs, multiple procedure reduction does not apply

S

APC payment reimbursement methodology: emergency department encounters

T

Reasonable cost reimbursement methodology: Pass-through devices with no copayment

V

Composite APC payment: APC 8004 Ultrasound

Intermediate Exercise

1. Practice with APCs (Level 3Interpreting)

This assignment is designed to give the student practice with understanding APC concepts, groups, and payment rates. Students will use the most recent OPPS Addendum A and Addendum B. Addendums A and B are located at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates

INSTRUCTIONS: Locate the most recent OPPS Addendum A and Addendum B on the Medicare website.

1. Using Addendum A, identify a set (example is Pathology) of surgical APCs that are paid at the full rate. Exclude New Technology.

a. Set:

b. Status Indicator

2. Using Addendum A, identify a set (example is Airway Endoscopy) of surgical APCs that are paid at a discounted rate when multiple procedures are performed. Exclude New Technology.

a. Set:

b. Status Indicator

3. In Addendum A, locate APCs 5111-5116. APC 5111 is SI T and the remaining APCS are SI J1. How is SI J1 different from T?

4. Using Addendum B, locate five packaged codes/services from different areas of the code set (i.e., not all five from anesthesia).

1. X

2. X

3. X

4. X

5. X

5. Packaged services are not separately payable. Are you surprised that any of the services you identified in question #4 are not separately payable? What statistics or measures are impacted when a packaged service is provided during a clinic visit? For example, an immunization provided during a clinic visit.

6. Using Addendum B, identify an inpatient-only procedure. Give a reason why this procedure would be approved for the inpatient setting but not the outpatient setting.

7. Scenarios. Identify the APCs and payment status indicators (SIs) for each scenario (Addendum B). Which APCs are not packaged and would yield reimbursement for the facility?

a. Repair of lower jaw fracture is performed (21470). X-rays of the jaw (70110) and facial bones (70150) are performed. List the APCs and SIs. Which APC(s) are separately payable?

b. Patient evaluated in the ED (99282) for a racoon bite to the arm. Rabies vaccine was given to the patient (90471 and 90675). List the APCs and SIs. Which APC(s) are separately payable?

c. Patient has a dermatology appointment. The physician drains a pilonidal cyst (10080) on the patients lower back near the tailbone. Local anesthesia is provided (00300). Additionally, the physician removes a callus on the patients big right toe (11055). Lastly, the physician removes 8 skin tags (11200). List the APCs and SIs. Which APC(s) are separately payable?

8. How could the facility/physician circumnavigate the APC packaging rules for scenario 7C in order to receive additional reimbursement?