Exceeding the APC rate


Johnson City, TN
Best answers
Hello everyone!
So I am new to Ambulatory Surgical Center billing/coding. I've been at it for about 2 years since 2021. I am getting denials all of the sudden from Amerigroup on my CPT codes 66821 (yag laser) & 66984 (cataract removal) codes as exceeding the Ambulatory Classification Rate.
I have googled myself in a circle trying to understand this. Can anyone help me figure this out? Amerigroup is the only one doing this and only for their Medicare products.
I just don't even know where to start to begin to understand how this works.
Help please!
I have never heard of this. Is it an actual denial (i.e. the entire claim is denied)? Or are they just using this denial reason for the charges that exceed the APC payment rate? If they're just denying the lines on the claim that are zero paid because the APC was paid in full on a different line, that would just be a contractual adjustment not an actual denial. Have you spoken to anyone at Amerigroup for clarification?
There is an NCCI edit between the codes 66984 and 66821. Were both of these procedures done on the same eye?