Page 22 - Technical Guide - Ortho C_IM RV4

Hospital Outpatient Coding (APCs)

Ambu latorypaymentclassifications (AP Cs) is the prospective payment system Medicare use storeimburse hospita lsforou tpatientservices. Each CPT code
fora significantprocedureisassigned to a specific APC class based onclinicaland resource similarities. EachAPC hasa relativeweightthatindicatesits
rank compared to allotherproceduresin terms of the relative costs. The relativeweightis then converted to a flat paymentamountusing a standardized
conversion factor.
Multiple AP Cs can be assigned for the same case if multi pie proced uresare performed. The status indicator (SI) signifies how a code is hand led for
payment.Statuslndica tore indicatesaninpatient procedure, Notpaid underO PPS.Patient sho u Id be ad milted and billed asaninpatient. Statusindicator
J l will trigger a comprehensive AP C paymentfortheclaim, meaning a sing le AP C will be paidwhilea llotheritemsand services on the same date of
servicewillno longergenerate separate payment .StatusindicatorN services are paid under the OP PS, bu ttheirpayment is packaged into payment fora
separately paid service, it is a packaged service/item; no separate payment made. Local carrier determnatims may also apply to N when separate payment
is allowed.StatusindicatorT means that the code pays at l 00%of the rate when it is the only procedure oristhe highest-weighted procedure, but pays at
50%of the rate when itis submitted with another higher-weighted procedure.
For Medicare, with a fewexceptions, the APC paymentforthe proced urecodeisconsidered complete. lngeneral, separate paymentisnotmadefor
Imp tinted devices. Instead, payment for imp tints used in the procedure is included in the payment for the procedure. However, prvate payers may rave
i
carve-outs forimplants.
CPT® SI Relative Average
Code Description APC APC Title Weight Payment
Level IVMusculoskeletal
27870 Arthrodesis, ankle, open 0052 Procedures Except Hand T 85.2438 $6,320
and Foot
Level II Foot Musculoskeleta
28705 Arthrodesis; pantalar 0056 T 70.3645 $5,217
Procedures
Level V Musculoskeletal
28715 Arthrodesis, triple 0425 Procedures Except Hand JI 137.8399 $10,220
and Foot
Level II Foot Musculoskeletal
28725 Arthrodesis, subtalar 0056 T 70.3645 $5,217
Procedures
Arthroscopy, ankle (tibiotalar and fi bu Iota lar joints),
29899 0042 Level II Artrwscopy T 58.5867 $4,344
surgical; with ankle arthrodesis
Reference: Medicare Program: Hospital Outpatient Prospective Payment System Final Rule Addendum C - Fina( HCPCS Codes Payable Under the 2015 OPPS by APC

Ambulatory Surgery Center (ASC) Coding

Medicare's prospective payment system for ASCs is based m the systems used for hospital outpatient services and physician office-based procedures. Each
CPT code for an ASC-covered procedure is assigned a relative weight and flat payment amount whch is then adjusted for the ASC setting.
Multiple procedure scan be paid forthe same case if mu ltiplecodesare submitted. The paymentindicator (Pl) signifieshowa cod eishandled forpayment.
l
Specifically, payment indicator A2 meansa su rgica I proced u rewhose paymentis based on the hospita outpatientrate. Paymentindicator J8 indicates
Device-intensive procedure; paid at adjusted rate. Payment indicator NI indicates a packaged procedure/item; no separate payment made. NA indicates
surgical procedures excluded from payment in AS Cs for CY2015. When the Multiple Procedure Discountis Yes, it indicates that the code pays at l 00%of
the rate when itis the onlyprocedure oris the highest-weighted procedure, but pays at 50%of the rate when it is submitted with another higher-weighted
procedure.
For Medicare, with a few exceptions, the ASC paymentforthe procedure code isconsid ered complete. In genera I, separate paymentisnotmadefor
implanted devices. Instead, payment for implants used in the procedure is included in the payment for the procedure. However, private payers may have
carve-outs forimplants.
Multi· Rel�t1ve ...
I I • Procedure Weig ht
Discounting?
27870 Artrrooesis, ankle, open A2 y 78.6374 $3,466
28705 Arth'ooesis; pant a lar A2 y 64.9113 $2,861
28715 Artrrooesis, triple JS N 177.9456 $7,842
28725 Artrrooesis, subtalar A2 y 64.9113 $2,861
Arth'oscopy, ankle [tibiotalar and fi bulotalar jdnts), surgical; with ankle
29899 A2 y 54.0462 $2,382
arthrodesis
Reference: Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Final Rule, Addendum AA --Final ASCCovered Surgical Procedures for CY 2015 {Including
Surgical Procedures for Which Payment is Packaged), Addendum ££--Surgical Procedures Proposed to be Excluded from Payment in ASCsfor CY 2015

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