APC reimbursement allows fixed pricing of services to be established at the HCPCS code level. This allows us to base reimbursement on the actual services/procedures provided in an outpatient setting. Fee schedule pricing, as well as APC pricing, has become the industry standard for outpatient reimbursement.

APC reimbursement includes these components:

• Established fees for APCs
• Fee schedules for some HCPCS codes (predominantly labs and therapies)
• Discount off of charges

Based upon the procedure you file, a claim can have any combination of these three components.

The Centers for Medicare and Medicaid Services (CMS) defines incidental services within the APC grouper software as services that are normally provided in conjunction with other services. CMS considered all incidental charges when it established the rates with no separate reimbursement allowed for the incidental services.

We base our edits on validations in the version of the CMS grouper used at the time we process the claim. We will accept all valid HCPCS and CPT codes. If the code is too new to be included in the current grouper we use, we will reimburse based on a discount off of charges (as defined in the hospital’s agreement).

We will have to void the original claim, get a refund on that originally processed claim, and process the corrected claim as a new claim. It is important that corrected claims submissions be minimized. We request that you review your volume of corrected claims and make sure your procedures for initial submissions are sufficient to minimize the number of corrected claims.

Reimbursement for codes and charges submitted with "N" status indicators are allocated in APC codes (i.e. no separate reimbursement is provided for codes that have an "N" status indicator) and reimbursement for codes and charges submitted with "E" status indicators are based generally on a fee schedule.

No. The service is covered with a zero allowable, so you can not bill the patient.