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Issue Number - Name
0101-Outpatient Hospital Comprehensive APC Coding
Review Type
Complex
Claim Type
Outpatient Hospital
Region and State
RAC 1-4
All States
Date Approved
2018-07-10

Description

Comprehensive APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.

Affected Code(s)

Claims with only status indicator (SI) = J1

Applicable Policy References

  • 42 Code of Federal Regulations Sections: 414, 419
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 4
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4
  • American Medical Association (AMA), Current Procedure Terminology, Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1) and APCs for Hospital Part B services paid through a comprehensive APC (SI = J1)
  • Integrated OCE (IOCE) CMS Specifications Appendix L: Comprehensive APC Assignment Logic (OPPS Only, V16.0, Effective 01/01/2015 through V19.0 Effective 01/01/2018