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Thread: CMS groupers

  1. #1

    Default CMS groupers

    AAPC: Back to School
    Ok, I'm blown away by this one but maybe someone can shed light on it for me.

    I have a commercial payer that has a contract based on CMS groupers which haven't been used since 2007 but we continue to use the same groupers from 2007 until a new contract can be negociated. But there is a new code in 2011 which obviously would not be grouped because it was not a code in 2007. They paid it at a grouper 3 rate with is not a default grouper for this payer. I called and they said it was based on CMS groupers which this code is listed under grouper 3. I explained that it's a new code and no grouper assignment so should be default. They said that CMS continues to assign groupers. Well, now let me back up. I understand that Medicare changed from 10 groupers to one hundred-something groupers (if I remember correctly). Anyway, I'm unable to find the grouper listing now.

    Can anyone direct me to the CMS groupers?

  2. #2

    Default OPPS APC groups 2011


    Addendum B updates

    January 2011

    What is the CPT? Maybe I can help you follow the insurance company's logic. Why are they using a 2007 list?
    Last edited by blipps; 07-05-2011 at 05:23 PM. Reason: additional comments

  3. #3


    I don't know why they're using 2007 but I wish we could get an updated contract so we don't had to deal with all this bologna.

    I reviewed the list and I guess I don't know how to read it.

    I would love some help. It's CPT code 31296.

    Thank you!

  4. #4

    Default 31296

    These procedure codes are new in 2011 (31295, 96 & 97). In the 2011 APC grouper they fall into the same APC as CPTs 31239, 31254, 31255, 31256, 31267, 31276, 31287, 31288, 31292, 31293, 31294. You should be able to compare what these codes reimburse and it should be the same for the balloon procedures.

    Good Luck!

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