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Ambulatory Payment Classifications (APCs) Cheat Sheet by

Ambulatory Payment Classifications (APCs)
medical     payment     healthcare     ambulatory     classifications     apc     outpatient


In most cases, the unit of payment under the OPPS is the APC. CMS assigns individual services (HCPCS codes) to APCs based on similar clinical charac­ter­istics and similar costs. The payment rate and copayment calculated for an APC apply to each service within the APC. Sometimes new services are assigned to New Technology APCs, which are based on similarity of resource use only, until cost data are available to permit assignment to a clinical APC. The payment rate for a New Technology APC is set at the midpoint of the applicable New Technology APC’s cost range.

Services Paid Separately

● Many surgical, diagno­stic, and nonsur­gical therap­eutic procedures
● Blood and blood products
● Most clinic and ED visits
● Some drugs, biolog­icals, and radiop­har­mac­eut­icals
● Brachy­therapy sources
● Corneal tissue acquis­ition costs and
● Certain preventive services
Some services are paid separa­tely, including but not limited to

Partial hospit­ali­zation

Paid on a per diem basis. The payment represents the cost of a day of
intensive and structured outpatient mental health care in a partial hospit­ali­zation program provided in the hospital or in a CMHC. Beginning January 1, 2017, there is one APC (for furnishing three or more services per day) for partial hospit­ali­zation furnished by hospitals and one APC (for furnishing three or
more services per day) for partial hospit­ali­zation furnished by CMHCs


“Packa­ging,” or grouping payment of dependent, ancillary, suppor­tive, and adjunctive items and services into the payment for the associated primary procedure or service, is a critical feature of the OPPS. Packaging encourages efficient use of hospital resources. Separate payments are not made for packaged services, which are considered an integral part of another service that is paid under the OPPS.

Medicare Outpatient Payment

Packaged Services

● All supplies
● Ancillary services
● Anesthesia
● Operating and recovery room use
● Clinical diagnostic laboratory tests
● Procedures described by add-on codes
● Implan­table medical devices (such as pacema­kers)
● Inexpe­nsive drugs under a per-day drug threshold packaging amount
● Drugs, biolog­icals, and radiop­har­mac­eut­icals functi­oning as supplies (including diagnostic radiop­har­mac­eut­icals, contrast agents, stress agents, implan­table biolog­icals, and skin substi­tutes)
● Guidance services
● Image processing services
● Intrao­per­ative services
● Imaging superv­ision and interp­ret­ation services and
● Observ­ation services

Effective Jan 1, 2015

CMS establ­ished compre­hensive APCs to provide all-in­clusive payments for certain proced­ures. This policy packages payment for all items and services typically packaged under the OPPS. It also packages payment for other items and services not typically packaged under the OPPS. The single payment for a compre­hensive APC excludes services that cannot be covered OPD services, cannot by statute be paid under the OPPS, and services separately paid as required by statute

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