Hospital Outpatient
Coding and Reimbursement Process
Similar
to physicians, hospitals use ICD-9-CM codes for diagnoses and CPT or HCPCS II
codes for procedures for outpatient encounters. For Medicare, hospital
outpatient reimbursement is under the Ambulatory Payment Classification (APC)
system.
Each
CPT and HCPCS II code is assigned to an APC group with a unique relative
weight, which is then converted into the payment amount. Unlike DRGs, multiple
APCs can be assigned and paid for each outpatient encounter, depending on the procedure
performed. Additional amounts may also be available for specific pass-through
devices.
Medicare
has used APCs for hospital outpatient reimbursement since 2000.
Changes
to APCs and CPT procedure codes are effective January 1st
