Description
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 billed services affecting or potentially affecting APC reimbursement.
Affected Code(s)
Claims with status indicators (SI) = J1, T, S, and K
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. 42 CFR §419- Prospective Payment System for Hospital Outpatient Department Services
9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS) §§10.1-10.5, 20, 40-50
10. American Medical Association (AMA), Current Procedure Terminology (CPT) Codebook
11. American Medical Association (AMA), Current Procedure Terminology (CPT), Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1), APCs for Hospital Part B services paid through a comprehensive APC (SI = J1), Procedure or Service, Not Discounted When Multiple (SI=S), Procedure or Service, Multiple Reduction Applies (SI = T)
12. American Medical Association (AMA) Current Procedural Terminology (CPT) Assistant
13. Medicare National Correct Coding Initiative (NCCI) Policy Manual
14. CMS Hospital Outpatient PPS, Addendum B Updates