APC Grouper

CodeCheck APC Grouper is the place for you to submit CPT/HCPCS codes where APC pricing and logic are applied, and return results that are grouped and priced according to OPPS payment formula, estimated total payment, and CCI bundling issues (if applicable).

Perform an APC Grouper CodeCheck

Use the following procedure to input up to 15 CPT/HCPCS codes and view approximate reimbursement amounts.

Procedure

Select CodeCheck > APC Grouper. The APC Grouper Input page opens.
Select a Date of Service.

Note: The date of service that you select will automatically populate in the first line item Date of Service field.

Choose a Diagnosis code set: ICD-9 or ICD-10.

Note: When you select a date of service that is before the ICD-10 cutover date of October 1, 2015, the ICD radio button automatically defaults to ICD-9.

Enter the patient’s Age and Gender.

Note: The default Age is 65.

Select the Apply 2% Sequestration check box if you would like to include the 2% Medicare 2% sequestration reduction information in your results.
Enter a CPT/HCPCS code and any applicable Modifiers, Revenue Codes, or Service Units.

Note: Up to 30 rows of data are supported. Data rows are added automatically once a line is filled, or you can click the Add Row button to add additional Procedure Information rows.

Choose the Date of Service.
Enter any applicable ICD Diagnosis Codes into the Diagnosis Information section.
Click Submit. The APC Grouper results page displays.

View APC Grouper CodeCheck Results

APC Grouper results display the APCs in order of reimbursement amount.
The APC with the highest reimbursement amount (per code) is listed first.
APC groups with the same reimbursement are listed together in numerical order by APC.
Results show the line payment amount after each HCPCS displayed in the group so users can see what is discounted.
A warning section shows codes not associated with any APC.

Any CCI issues found are listed below the APC information.

The CCI Version indicates the date(s) each version was effective.
Medically Unlikely Edits are displayed for Professional, Facility, and Durable Medical Equipment as applicable.
The CCI Modifiers legend explains the superscript shown after each CPT/HCPCS code listed in the CCI edit data.

A Column 1 Code shows your selected code as a COMPREHENSIVE code. These are codes that generally cannot be used with the selected code, since the selected code is included in them. Codes that display a superscript 1 have modifiers that can resolve the CCI edit. Codes that have a superscript of 0 cannot resolve the CCI edit.
Mutually Exclusive codes are also shown as Column 1 Codes. The selected code cannot generally be used with these as they are contradictory or redundant with it.
Column 2 view shows your selected code as a COMPONENT code. These are codes that generally cannot be used with the selected code, since the selected code is included in them.

Field Descriptions

The following table describes the fields in your search results for CodeCheck APC Grouper. Not all fields may be relevant to your particular search.

CMS groups procedures with similar clinical and resource utilization characteristics, but monitors claims data to determine if payment rates are equitable.

Field	Description
Date of Service	Displays the date of service that you entered, or by default the one displayed in your main toolbar.
Wage Index	Wage-adjusted calculation.
Provider Number	The healthcare organization’s Medicare provider number.
2% Sequestration	The Medicare 2% sequestration reduction that went into effect on April 1, 2013.
APC Code	Displays the APC code information for the CPT/HCPCS code(s) entered. Click the code to view detailed information.
APC Description	A detailed APC description.
SI	APC Status Indicator. Can be shown for both APC and HCPCS codes. Click the indicator to view the status definition The Status Indicator lets the facility know whether the procedure code is available for separate reimbursement under the OPPS system (or not) and what payment policies may apply to the procedure.
HCPCS Code	Displays the HCPCS code(s) you entered.
HCPCS Description	A description of the entered HCPCS code(s).
Discounted Payment Total	The discounted payment total for all procedures listed.
Wage Adjusted APC Payment	Shows national unadjusted payment rate amount, with the wage adjusted payment rate calculations completed. This is the APC payment, and includes the facility’s reimbursement as well as the patient’s responsibility. If you are looking at a remittance, this would be the Medicare Approved Amount.
Sub-totaled Adjusted Payments	A subtotaling of the wage adjusted APC payment amounts.
National Unadjusted Coinsurance	Amount determined by CMS as the patient’s coinsurance amount. Medicare reimbursement for the physician side is an 80/20 split. Medicare would pay 80% of their approved amount and the patient would be responsible for the 20%. When OPPS was set up, Medicare wasn’t able to cover all of this cost, so they instituted a 60/40 split. They are working towards the 80/20 split and have made it there for many codes. They are gradually changing the National Coinsurance to the Minimum Coinsurance (which is the 20%). When there are zeros in this column, the patient’s coinsurance has made it to the 80/20 split.
Minimum Unadjusted Coinsurance	20% of the National Payment Rate. Wage adjustment can be made to this amount to determine the patient’s responsibility for the procedure.