outpatient prospective payment system indicators

#Outpatient prospective payment system indicators code

However, the APC is also assigned a Status Indicator (SI) for example, APC 5021, Level 1 Type A ED Visits, is assigned a 'V' status indicator assigned APC assigned category.

#Outpatient prospective payment system indicators code

Let's look deeper into the methodology we understand each CPT/HCPCS code is assigned to an APC. The J1 status indicator is the outpatient version, similar to the inpatient diagnosis-related groups (DRGs) payment system.įigure 2. These are all bundled into Emergency Department visits under APCs 5021- 5025 Level 1-5 (type A ED visits), meaning 'Payment for all covered Part B services on the claim is packaged into a single payment.' Reporting any of the APC codes 5021-5025 indicates all other services are bundled if they have a status indicator of J2. It is interesting to mention there are only 13 codes assigned to the J2 status indicator, which include CPT codes 99281, G0379-G0484, and G0463. Each code is assigned a status indicator of 'J2- Paid under OPPS all covered part B services on the claim are packaged with the primary.' This does not include ancillary services, such as X-rays and labs. Generally owned by a group of physicians and publicly owned and provides urgent care without a scheduled appointment, it may not be open 24 hours a day, 7 days a week.ĮD visits are reported using the Evaluation and Management services for 'Emergency department services', using CPT codes 99281- 99285.

Licensed by the state and is open 24 hours a day, 7 days a week Types of Emergency Departments Type of ED The type of emergency department determines which HCPCS codes are used to report the location according to CMS OPPS Visit Codes - FAQs. Within this payment system, the OPPS defines two types of emergency departments type A and type B both are paid under Part B by Medicare using the OPPS. Payment for Emergency department visits falls under the Hospital Outpatient Prospective Payment System (OPPS). See the Place of service codes for the ED in ( figure 2. Place of service 22 is used when reporting Outpatient Hospital services diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. NOTE: Do not confuse Urgent care and Emergency room visits with on-campus hospital outpatient clinic. Notice (figure 1.) that the J1 and J2 indicators are labeled as 'Hosptial Part B,' meaning outpatient emergency room visits are processed under Part B of the beneficiary's Medicare insurance. For detailed information, see Understanding ASCs and APCs: Indicators and Place of Service. The place of service is an integral part of this payment process, as the place of service will trigger reimbursement rules. Therefore, the status indicator reflects the payment method an example would be the J1 or J2 status indicators we will explain more in-depth about status indicators later in this article.

Some CPT/HCPCS codes are designed to be paid under a specific APC (payment methodology) with services packaged into the primary APC payment by assigning a Status Indicator (SI) to every CPT/HCPCS code. (see Table 2 below for payment status indicators.) With few exceptions, all other services reported on a hospital outpatient claim in combination with the primary service are considered to be related to the delivery of the primary service and packaged into a single APC payment for the primary service'. APCs are the primary type of payment made under the OPPS, comprising groupings of CPT/HCPCS codes with similar clinical characteristics and costs to help consolidate payments the reimbursement amount covers each service included in the APC grouping (similar to DRG groupings).Īccording to CMS, 'Comprehensive APCs provide a single payment for a primary service, and payment for all adjunctive services reported on the same claim is packaged into payment for the primary service. Most payers also use the APC reimbursement system however, there may be some differences in payer policies (always review your specific payer policy). Sep 15th, 2022 - Reviewed/Updated Nov 8thĬMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). News - industry news & Find-A-Code updatesīy Christine Woolstenhulme, QMC QCC CMCS CPC CMRS.Marketplace - recommended products & services.Library - buy digital books from Find-A-Code.Bookstore - buy physical books & cheat sheets.Subjects - Audits, E&M, HIPAA, Practice Mgt, etc.Specialties - Cardiology, ENT, Family Practice, etc.Payers - Medicare, Medicaid, BC/BS, Aetna, etc.Facilities & Organizations - ACOs, Hospitals, etc.