Coding, Classification & Reimbursement

Topic: Comprehensive APC's- packaging of Prosthetics and Orthotics? 

1.  Comprehensive APC's- packaging of Prosthetics and Orthotics?

Posted 11-14-2017 14:52
Can someone please help confirm if prosthetics and orthotics (L codes) are packaged into C-APC's (comprehensive APC's)?  For example HCPC code L4361 - Pneumatic Walking boot prefabricated off the shelf has a status indicator "A".  If this was billed on the same claim as another CPT that falls into a C-APC, would the code L4361 be paid separately or bundled into the C-APC payment?
My understanding is that if there is any code that falls into status indicator J1 - that all items are bundled into the C-APC rate, even if the status indicator for L4361 is status indicator "A".  Much appreciated if someone can shed some light on this for me!

Thanks!
Amy Larson, RHIT, CCS-P

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Amy Larson
Independent Coding & Revenue Cycle Consultant
B.S. Healthcare Leadership,RHIT,CCS-P
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2.  RE: Comprehensive APC's- packaging of Prosthetics and Orthotics?

Posted 11-15-2017 09:21
SI "A" is not a packaged SI, and will be paid on the fee schedule.  The SI assignment always drives APC payment, so in your case, the L code will be paid through the fee schedule.
There are various packaged SIs, so when these are assigned, they are conditional to what ever is also reported on the claim.   The IOCE will look at all codes on claim and for those HCPCS codes assigned to a packaged SI (i.e. Q1, Q2, J1), if a certain code is not present on claim, there will be a default SI for payment applications.    A couple of links below may describe better.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-FR-Claims-Accounting.pdf
This one doesn't capture the packaged SIs, but all others -  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/downloads/CMS1392P_Addendum_D1.pdf

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Sheila Goethel
Coding Services Senior Manager
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3.  RE: Comprehensive APC's- packaging of Prosthetics and Orthotics?

Posted 12-06-2017 15:32
Sheila:

Thank you for your reply, I don't know how I didn't see it before now!.  Yes that was my original thought on this, however then second guessing began.  So as I understand it, any status indicator "A" items will be paid separately even though there may be a code with status indicator "J1" on the same claim.

Thanks so much!
Amy

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Amy Larson
Independent Coding & Revenue Cycle Consultant
B.S. Healthcare Leadership,RHIT,CCS-P
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4.  RE: Comprehensive APC's- packaging of Prosthetics and Orthotics?

Posted 3 days ago
Hi Sheila:

I thank you for your response, however I  just wanted to follow up on this topic.  I have done further research and in fact when a OPPS claim has any service with that falls into status indicator J1 (comprehensive APC) , all Part B services on the claim are in fact packaged into the comprehensive APC payment UNLESS the other services on the claim have a status indicator of  F, G, H, L or U.   Only these status indicators are paid separately with any status indicator J1 service (comprehensive APC).

This is an excerpt from the Comprehensive APC Processing (sI=J1)  Flowchart.  Except for services that are exempt by statute, all allowed adjunctive services submitted on the claim with a comprehensive APC procedure are packaged into the comprehensive APC payment (the SI is changed to N). Services that are excluded from packaging include ambulance, brachytherapy (SI=U), mammography, pass-through drugs, biologicals and devices (SI= G or H), preventive care including influenza and pneumococcal vaccines (SI=L), corneal tissue acquisition, certain CRNA services and Hepatitis B vaccines (SI = F). Services that are exempt by statute from the all-inclusive payment retain the standard APC (if applicable) and SI for standard processing.

I also ran some claim scenarios through an APC pricer and it did kick out the same result as mentioned above.  If CPT code  49440 (SI=J1) is billed with HCPC code B4088 (SI=A), the claims logic changes the status indicator for B4088 from an A to a N and packaged B4088 into 49440.  The same is true for any prosthetics and orthotics with a status indicator of A.  If they are billed with another service that is status indicator J1, they are also packaged and not paid separately.



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Amy Larson
Independent Coding & Revenue Cycle Consultant
B.S. Healthcare Leadership,RHIT,CCS-P
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