What is APC Pricer?
APC Pricer is a stand-alone Excel based OPPS Pricer that allows you to determine the OPPS reimbursement amount for an entire outpatient hospital claim (not just individual services). It resides on your PC and requires no special software.
What is the CMS Pricer?
The CMS PC Pricer is a tool used to estimate Medicare PPS payments. Generating an estimate requires the user of the PC Pricer to address complexities such as hospital acquired conditions, MS-DRG grouping, NUBC guidelines and Medicare Code Edits (MCE).
How does the APC system work?
APCs are an outpatient prospective payment system applicable only to hospitals and have no impact on physician payments under the Medicare Physician Fee Schedule. If the patient is admitted from a hospital clinic or ED, then there is no APC payment, and Medicare will pay the hospital under inpatient DRG methodology.
What is the outpatient prospective payment system?
The Outpatient Prospective Payment System (OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. The rate of reimbursement varies with the location of the hospital or clinic.
What is composite APC payment?
Composite APC A composite ambulatory payment classification (APC) is when a single payment rate for a service which is a combination of several HCPCS codes on the same date of service (or a different date) for several major procedures.
What services are included in APCs?
The system encompasses all provider-based ambulatory settings including same day surgery centers (ASCs), emergency departments (ED), and clinics, but excludes home visits, nursing home or inpatient admissions. APCs were based on Version 2.0 of the Ambulatory Patient Groups (APGs).
How is Medicare APC payment calculated?
The payments are calculated by multiplying the APCs relative weight by the OPPS conversion factor and then there is a minor adjustment for geographic location. The payment is divided into Medicare’s portion and patient co-pay. Co-pays vary between 20 and 40% of the APC payment rate.