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Assigning the correct APC

  1. #1
    Default Assigning the correct APC
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    Hi there

    I have for the most part only a physician coding background and have recently cultivated a new interest in Facility/Outpatient coding and I have a question. In reviewing the 2010 CY Addendum A on CMS website I found there are different levels of the same code (ie) I&D codes, Excision/Biopsy, Breast Sugery. I'm curious how one determines which Level in the Group Title section to use so as to assign the correct APC?

    http://www.cms.gov/apps/ama/license....2010_Add_A.zip


    This is all so fascinating and new to me. Any suggestions/tips you have that will help broaden my understanding of APC/ASC would be appreciated.

    Room2Grow, CPC

  2. #2
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    The CPT should be the same that the physician is reporting. What the documentation supports would determine which code it would be. What APC the CPT is grouped under does determine the coding for the case.

  3. #3
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    Oh Ok. Thank you for your response.

    Where would I find a list/excel sheet that includes APC, Group Title and CPT's? The link I sent in my previous post is all I could find. Does one exist?

    Thanks again for your help.

  4. #4
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    Columbia, MO
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    There is an APC listing, we have a book that lists out the APC, the CPC codes that are included and the rate of reimbursement. The Procedure codes in the facility are to match the physicians codes for the same procedure, always going by the documentation. The theory being if we are all looking at the same note and following the same rules then we should get the same codes. The facility E&M however is not required to match the physicians. The facility has its own unique criteria to determine the E&M and it is not based on the 95/97 physician guidelines. There are some specific rules that are to be followed as well as far as the application of the 25 and 27 modifiers and the G0 condition code. I suggest you look on the CMS website under transmittals and find the latest quarterly update to the OCE (outpatient code editor) It may answer some questions and bring up all new ones.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    http://www.cms.gov/HospitalOutpatientPPS/AU/

    Have you checked out addendum B.

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