Coding, Classification & Reimbursement

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

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

Posted 9 days ago
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 8 days ago
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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