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Update Infomation Release Plan

A hospital outpatient, for Medicare purposes, is defined in Chapter 6 (Hospital Services Covered Under Part B) of the Medicare Benefit Policy Manual, section 20.1 - Outpatient Defined, as follows:

"A person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital."

Medicare Manuals

Pass-Through Payment Status and New Technology APC

APC (Ambulatory Payment Classification)

APC Status Indicators / Codes

The status indicator provides information on the type of service represented by the APC. Common indicators are below; Addendum D1 of the 2006 HOPPS Final Rule lists them all.

Addendum D1. Payment Status Indicators for HOPPS

Indicator

Item/Code/Service

OPPS Payment Status

A

Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS.

Not paid under OPPS. Paid by fiscal intermediaries under a fee schedule or payment system other than OPPS.

G

Pass-Through Drugs and Biologicals

Paid under OPPS; Separate APC payment includes pass-through amount.

K

Non-Pass-Through Drugs and Biologicals

Paid under OPPS; Separate APC payment.

N

Items and Services Packaged into APC Rates

Paid under OPPS; Payment is packaged into payment for other services, including outliers. Therefore, there is no separate APC payment.

S

Significant Procedure, Not Discounted when Multiple

Paid under OPPS; Separate APC payment.

T

Significant Procedure, Multiple Reduction Applies

Paid under OPPS; Separate APC payment. The procedure with the highest weight will be paid at 100% while each additional surgical procedure will be paid at 50%.

X

Ancillary Services

Paid under OPPS; Separate APC payment.

Coding

HCPCS C-Codes

 

The HOPPS included "C" codes, or "pass-through" codes. Medicare created over 90 "pass-through" categories of devices, each category with its own specific "C" code.  If a hospital used a device that fell into a pass-through category, they could put the appropriate C-code on the bill they submitted to Medicare for additional payment. These were commonly known as "pass-through" payments and were designed to expire after two to three years, after which this additional payment would be folded into the relevant Ambulatory Payment Classification (APC) payment rates.

 

Though the pass-through payments for most C-codes no longer exist, Medicare does require that C-codes continue to be included on hospital claims paid under the OPPS.  This is done so that Medicare can adequately capture the resources required to provide services, and use this resource information to establish adequate payment rates in the future.  In fact, Medicare has defined certain procedures as being device-dependent, and claims for these procedures will be denied if they don’t also include the necessary C-codes.

 

Surgical Discounting

Outpatient Code Editor identifies the following situations so that Pricer will apply surgical discounting to the following situations:

  • When more than one type-T procedure billed on the same date of service (Status indicator "T" is assigned to HCPCS codes in Addendum B of the OPPS Final Rule to indicate surgical procedures to which the multiple procedure payment reduction applies.),

o        The highest paying APC will not be discounted.

o        All other type T procedure will be discounted 50%.

o        A HCPCS code with modifier 73 (terminated prior to anesthesia) will be discounted 50%.

o        A type-T procedure HCPCS code billed with modifier 50 (bilateral), is similar to billing for two procedures, one performed on the right side, and one on the left side. Therefore, when modifier 50 is billed,

§ If it has the highest paying APC of the type T procedures billed for the same date of service, only one of the procedures (right or left) will be discounted (100% + 50%). This will result in a payment of 150% of the APC.

§ If another type T procedure billed on the same date of service has the highest APC, both procedures (right and left) will be discounted (50% + 50%). This will result in a payment of 100% of the APC.

  • A non-type-T radiological procedure with a modifier 50 will be identified by the OCE to pay 200% of the APC since surgical discounting does not apply.