Ambulatory Payment Classification for IOCE Quarterly Release Files

$179 / year

APCs or “Ambulatory Payment Classifications” are the government’s method of paying facilities for outpatient services for the Medicare program. This dataset contains the APC differences between October, 2015 and January, 2016. These APC Codes for outpatient services are to be used for services provided from 2016-01 to 2016-03.

Complexity

APCs or “Ambulatory Payment Classifications” are the government’s method of paying facilities for outpatient services for the Medicare program. A part of the Federal Balanced Budget Act of 1997 required HCFA (now CMS) to create a new Medicare “Outpatient Prospective Payment System” (OPPS) for hospital outpatient services -analogous to the Medicare prospective payment system for hospital inpatients known as “Diagnosis Related Groups” or DRGs. This OPPS was implemented on August 1, 2000. APCs are an outpatient prospective payment system applicable only to hospitals, and have no impact on physician payments under the Medicare Physician Fee Schedule. APC payments are made only to hospitals when the Medicare outpatient is discharged from the ED or clinic or is transferred to another hospital (or another facility) which is not affiliated with the initial hospital where the patient received outpatient services. If the patient is admitted from a hospital clinic or ED, then there is no APC payment, and Medicare will pay the hospital under inpatient DRG methodology.
Each APC is composed of services which are similar in clinical intensity, resource utilization and cost. All services (identified by submission of CMS’ Healthcare Common Procedure Coding System (HCPCS) codes on the hospital’s UB 04 claim form) which are grouped under a specific APC result in an annually updated Medicare “prospective payment” for that particular APC. (Many HCPCS codes are derived directly from the AMA CPT.) Since this payment is a prospective and “fixed” payment to the hospital, the hospital is at risk for potential “profit or loss” with each APC payment it receives. The payments are calculated by multiplying the APCs relative weight by the OPPS conversion factor and then there is a minor adjustment for geographic location. The payment is divided into Medicare’s portion and patient co-pay. Co-pays vary between 20 and 40% of the APC payment rate. Eventually this percent will be capped at 20% of the payment rate.
APCs were created to transfer some of the financial risk for provision of outpatient services from the Federal government to the individual hospitals, thereby achieving potential cost-savings for the Medicare program. By transferring financial risk to hospitals, APCs incentivize hospitals to provide outpatient services economically, efficiently and profitably.

Date Created

2016-01-11

Last Modified

2019-04-1

Version

75

Update Frequency

Quarterly

Temporal Coverage

2016-01 to 2016-03

Spatial Coverage

United States

Source

John Snow Labs; Centers of Medicare and Medicaid Services;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

APC Classification, Outpatient Services for Medicare, Medicare OPPS, Diagnosis Related Groups, Updated Medicare OPPS

Other Titles

Integrated Outpatient Quarterly Release Files Version 17.0, Release, January, 2016, APC Differences between October,2015 and January, 2016 for IOCE Quarterly Release Files.

NameDescriptionTypeConstraints
ADMIdentifies the type of difference.string-
Ambulatory_Payment_Classification5 digit APC Valueintegerlevel : Nominal
Status_IndicatorMedicare has assigned each HCPCS/CPT code a letter that signifies whether Medicare will reimburse the service and how it will be reimbursed.string-
Payment_IndicatorMedicare has assigned each HCPCS/CPT code a letter that signifies whether Medicare will reimburse the service and how it will be reimbursed.integerlevel : Nominal
APC_PaymentPayment assigned to the APC.integerlevel : Nominal
APC_DescriptionAPC Descriptionstring-
Version_ComparedCurrent Version 62= January, 2016integerlevel : Nominal
Start_DateEffective date of “VER”date-
Ambulatory_Payment_ClassificationStatus_IndicatorPayment_IndicatorAPC_PaymentAPC_DescriptionVersion_ComparedStart_Date
1690K22298Hemin752019-04-01
1690K22303Hemin742019-01-01
1690K22304Hemin732018-10-01
1690K22236Hemin722018-07-01
9193G275Nivestym752019-04-01
9193K277Nivestym742019-01-01
1417K253736Gel-one742019-01-01
1417K250935Gel-one732018-10-01
1417K252787Gel-one722018-07-01
925K2108Factor viii752019-04-01