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Correct APC coding

liz

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When pricing for a procedure with multiple APC codes, do you add them all together or does Medicare only pay for the highest one?

Example: SCS implant 63685 (APC 5464) and 63650 (APC 5462)

You would code 63650, 63685-51, APC 5462 and APC 5464, right? or just 5464

Thanks, Liz
 

thomas7331

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Both of these APCs are status J1 which is a comprehensive rate. The reimbursement for the case will be the rate for the highest of the two; in this example it will be the rate for APC 5464 if both codes are submitted. But APC payments are solely a methodology for reimbursement and should not have any bearing on how you code for services - the codes submitted should be based on the procedures that were documented, not based on how Medicare is going to calculate their payment. The fact that 63650 does not get a separate or additional payment does not mean that it should be omitted from the claim. If both codes were performed, then both need to be reported.
 
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liz

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SCS coding

Thanks for your help. That's what I thought. Can you tell me if I was correct in adding the modifier 51. Should it be added to 63650 or 63085? With a 2 lead SCS, I'm thinking it should be 63650, 63650-59 and 63685-51.
 
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