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1 UPDATEABLE 2019 Outpatient Billing Expert A complete guide to APC and ASC daily billing requirements Power up your coding optum360coding.com

2 Contents Hospital Outpatient Prospective Payment System... APC 1 Facility Resources Excluded From the Ambulatory Payment Classification Payment... APC 1 Clinical Diagnostic Laboratory Services... APC 1 Facility Types of Services Included in OPPS... APC 2 Facility Resources Included in APC Payments... APC 2 Discounting for Multiple Services... APC 2 Copayments... APC 2 How are hospital outpatient APC payments calculated?... APC 2 Copayments for Preventive Services... APC 5 How to Determine if There Is an Outlier... APC 7 Payment Calculations for Pass-Through Devices...APC 10 Brachytherapy Sources...APC 10 Composite APCs...APC 10 Special Packaged Services...APC Clinical Diagnostic Laboratory Changes under OPPS...APC 23 Comprehensive APCs...APC 23 Guide to Table Use...APC 24 APC Group Information Category III Emerging Technology Services...APC 27 Integumentary System...APC 33 Musculoskeletal System...APC 43 Respiratory System...APC 77 Digestive System...APC 91 Urinary System... APC 107 Endocrine System... APC 121 Radiology... APC 137 Pathology and Laboratory... APC 153 Medicine... APC 161 APC Tables APC Table 1. List of 2015 APCs with Their Assigned HCPCS/CPT Codes... APC 183 APC Table 2. Drugs and Medical Devices Eligible for Pass-Through Payment... APC 213 APC Table 3. Wage Index Adjustments for Hospitals... APC 215 APC Table 4. Inpatient-Only Codes... APC 243 APC Table 5. HOPD Modifiers... APC 263 APC Table 6. Revenue Codes Requiring HCPCS Codes... APC 265 APC Table 7. Packaged Services for APC 267 APC Table 8. OPPS APCs That May Be Applicable for Offset for CY APC 269 APC Table 9A. Procedures That Require a Device Code... APC 271 APC Table 9B. Device Codes That Must Be Billed with an OPPS Procedure... APC 275 APC Table 10. Primary and Add-on Procedure Code Pairs... APC 277 Freestanding Ambulatory Surgery Centers... ASC 1 Revised ASC Payment System... ASC 1 ASC Procedures List... ASC 1 ASC Scope of Services... ASC 2 ASC Payment System... ASC 4 Guide to Table Use... ASC 9 ASC Group Information Emerging Technology Services...ASC 11 Integumentary System...ASC 21 Musculoskeletal System...ASC 31 Respiratory System...ASC 69 Digestive System...ASC 93 Urinary System... ASC 113 v

3 Outpatient Billing Expert APC GROUP INFORMATION: MUSCULOSKELETAL SYSTEM CPT Code Coverage Effective Date of Changes APC Group APC status Payment National Unadjusted Copayment s I&d abscess subfascial 01/01/ T $ $ s Explore wound neck 01/01/ T $ $ s Explore wound chest 01/01/ T $1, $ s Explore wound abdomen 01/01/ T $1, $ s Explore wound extremity 01/01/ T $ $ s Excise epiphyseal bar 01/01/ T $3, $ s Muscle biopsy 01/01/ T $1, $ s Deep muscle biopsy 01/01/ T $1, $ s Needle biopsy muscle 01/01/ T $1, $ s Bone biopsy trocar/needle 01/01/ T $ $ s Bone biopsy trocar/needle 01/01/ T $1, $ s Bone biopsy excisional 01/01/ T $1, $ s Bone biopsy excisional 01/01/ T $1, $ s Open bone biopsy 01/01/ T $2, $ s Open bone biopsy 01/01/ T $2, $ s Injection of sinus tract 01/01/ T $ $ Inject sinus tract for x-ray 01/01/09 N s Removal of foreign body 01/01/ T $ $ s Removal of foreign body 01/01/ T $1, $ s Ther injection carp tunnel 01/01/ T $ $42.25 s Inj dupuytren cord w/enzyme 01/01/ T $ $42.25 s Inj tendon sheath/ligament 01/01/ T $ $42.25 s Inj tendon origin/insertion 01/01/ T $ $42.25 s Inj trigger point 1/2 muscl 01/01/ T $ $42.25 s Inject trigger points 3/> 01/01/ T $ $42.25 s Place ndl musc/tis for rt 01/01/ T $2, $ s Drain/inj joint/bursa w/o us 01/01/ T $ $42.25 l Drain/inj joint/bursa w/us 01/01/ T $ $42.25 s Drain/inj joint/bursa w/o us 01/01/ T $ $42.25 l Drain/inj joint/bursa w/us 01/01/ T $ $42.25 s Drain/inj joint/bursa w/o us 01/01/ T $ $42.25 l Drain/inj joint/bursa w/us 01/01/ T $ $42.25 s Aspirate/inj ganglion cyst 01/01/ T $ $42.25 s Treatment of bone cyst 01/01/ T $ $97.47 s Insert and remove bone pin 01/01/ T $2, $ s Apply rem fixation device 01/01/ Q2 $ $ Application of head brace 01/01/09 C s Application of pelvis brace 01/01/ T $1, $ s Application of thigh brace 01/01/ T $2, $ Application of halo 01/01/09 C s Removal of fixation device 01/01/ Q1 $ $26.35 s Removal of support implant 01/01/ Q2 $1, $ s Removal of support implant 01/01/ Q2 $1, $ s Apply bone fixation device 01/01/ T $2, $ s Apply bone fixation device 01/01/ T $2, $ Musculoskeletal System A AMB D DME E ESRD H HH L LAB M MAM R PEN X PHY P REHAB APC 43

4 Outpatient Billing Expert APC GROUP INFORMATION: RESPIRATORY SYSTEM CPT Code Coverage Effective Date of Changes APC Group APC status Payment National Unadjusted Copayment s Drainage of nose lesion 01/01/ T $ $25.95 s Drainage of nose lesion 01/01/ T $ $72.66 s Intranasal biopsy 01/01/ T $ $ s Removal of nose polyp(s) 01/01/ T $ $ s Removal of nose polyp(s) 01/01/ T $1, $ s Removal of intranasal lesion 01/01/ T $1, $ s Removal of intranasal lesion 01/01/ T $1, $ s Revision of nose 01/01/ T $1, $ s Removal of nose lesion 01/01/ T $1, $ s Removal of nose lesion 01/01/ T $3, $ s Excise inferior turbinate 01/01/ T $1, $ s Resect inferior turbinate 01/01/ T $1, $ s Partial removal of nose 01/01/ T $3, $ s Removal of nose 01/01/ T $3, $ s Injection treatment of nose 01/01/ T $ $ s Nasal sinus therapy 01/01/ T $ $ s Insert nasal septal button 01/01/ T $1, $ s Remove nasal foreign body 01/01/ Q1 $ $26.35 s Remove nasal foreign body 01/01/ T $1, $ s Remove nasal foreign body 01/01/ T $1, $ s Reconstruction of nose 01/01/ T $1, $ s Reconstruction of nose 01/01/ T $3, $ s Reconstruction of nose 01/01/ T $3, $ s Revision of nose 01/01/ T $1, $ s Revision of nose 01/01/ T $3, $ s Revision of nose 01/01/ T $3, $ s Revision of nose 01/01/ T $3, $ s Revision of nose 01/01/ T $3, $ s Repair nasal stenosis 01/01/ T $3, $ s Repair of nasal septum 01/01/ T $1, $ s Repair nasal defect 01/01/ T $3, $ s Repair nasal defect 01/01/ T $3, $ s Release of nasal adhesions 01/01/ T $ $72.66 s Repair upper jaw fistula 01/01/ T $3, $ s Repair mouth/nose fistula 01/01/ T $3, $ s Intranasal reconstruction 01/01/ T $3, $ s Repair nasal septum defect 01/01/ T $1, $ s Ablate inf turbinate superf 01/01/ T $ $ s Ablate inf turbinate submuc 01/01/ T $1, $ s Control of nosebleed 01/01/ Q1 $ $26.35 s Control of nosebleed 01/01/ T $ $25.95 s Control of nosebleed 01/01/ T $ $25.95 s Repeat control of nosebleed 01/01/ T $ $25.95 s Ligation nasal sinus artery 01/01/ T $2, $ s Ligation upper jaw artery 01/01/ T $2, $ Respiratory System A AMB D DME E ESRD H HH L LAB M MAM R PEN X PHY P REHAB APC 77

5 Outpatient Billing Expert ASC GROUP INFORMATION: DIGESTIVE SYSTEM CPT Code Subject to Discount Effective Date of Change ASC Payment ASC Payment ASC Copayment Biopsy of lip Y 07/01/15 P3 $82.65 $ Partial excision of lip Y 01/01/15 A2 $ $ Partial excision of lip Y 01/01/15 A2 $1, $ Partial excision of lip Y 01/01/15 A2 $ $ Reconstruct lip with flap Y 01/01/15 A2 $1, $ Reconstruct lip with flap Y 01/01/15 A2 $2, $ Partial removal of lip Y 01/01/15 A2 $1, $ Repair lip Y 01/01/15 A2 $ $ Repair lip Y 01/01/15 A2 $ $ Repair lip Y 01/01/15 A2 $ $ Repair cleft lip/nasal Y 01/01/15 A2 $2, $ Repair cleft lip/nasal Y 01/01/15 A2 $2, $ Repair cleft lip/nasal Y 01/01/15 R2 $2, $ Repair cleft lip/nasal Y 01/01/15 A2 $2, $ Repair cleft lip/nasal Y 01/01/15 A2 $2, $ Lip surgery procedure 01/01/15 IO Drainage of mouth lesion Y 01/01/15 P2 $88.75 $ Drainage of mouth lesion Y 01/01/15 A2 $ $ Removal foreign body mouth N 01/01/15 N Removal foreign body mouth Y 07/01/15 P3 $ $ Incision of lip fold Y 07/01/15 P3 $99.54 $ Biopsy of mouth lesion Y 07/01/15 P3 $ $ Excision of mouth lesion Y 07/01/15 P3 $ $ Excise/repair mouth lesion Y 07/01/15 P3 $ $ Excise/repair mouth lesion Y 01/01/15 A2 $1, $ Excision of mouth lesion Y 01/01/15 A2 $1, $ Excise oral mucosa for graft Y 01/01/15 A2 $ $ Excise lip or cheek fold Y 01/01/15 A2 $ $ Treatment of mouth lesion Y 07/01/15 P3 $ $ Repair mouth laceration Y 01/01/15 G2 $ $ Repair mouth laceration Y 01/01/15 A2 $ $ Reconstruction of mouth Y 01/01/15 A2 $1, $ Reconstruction of mouth Y 01/01/15 A2 $2, $ Reconstruction of mouth Y 01/01/15 A2 $1, $ Reconstruction of mouth Y 01/01/15 A2 $2, $ Reconstruction of mouth Y 01/01/15 A2 $2, $ Mouth surgery procedure 01/01/15 IO Drainage of mouth lesion Y 07/01/15 P3 $ $ Drainage of mouth lesion Y 01/01/15 A2 $ $ Drainage of mouth lesion Y 01/01/15 A2 $1, $ Drainage of mouth lesion Y 01/01/15 A2 $1, $ Drainage of mouth lesion Y 01/01/15 A2 $ $ Drainage of mouth lesion Y 01/01/15 A2 $ $ Incision of tongue fold Y 01/01/15 A2 $ $ Drainage of mouth lesion Y 01/01/15 A2 $ $ Drainage of mouth lesion Y 01/01/15 A2 $1, $ Drainage of mouth lesion Y 01/01/15 A2 $ $ Digestive System Deleted Code l New Code Revised Code ASC 93