APCActive™
ActiveX Outpatient PPS (OPPS) Components

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Introducing APCActive™ Outpatient PPS (OPPS) Components

APCActive™ was developed in response to the implementation of the Medicare outpatient prospective payment system (OPPS). The Omnibus Budget Reconciliation Act (OBRA) of 1986 called for the development of a prospective payment system for outpatient care. The OPPS developed by CMS is the outpatient equivalent of the inpatient DRG-based PPS. The basic unit of payment in the inpatient PPS is a hospital admission while the basic unit of payment in the OPPS is an outpatient visit.

Like the inpatient system based on the Diagnosis Related Groups (DRGs), each APC has a pre-established prospective payment amount associated with it. However, unlike the inpatient system that assigns a patient to a single DRG, multiple APCs can be assigned to one outpatient record. If a patient has multiple outpatient services during a single visit, the total payment for the visit is computed as the sum of the individual payments for each service.

There are two APCActive™ Components:

APCActive™ Code Editor DLL combines editing logic with the new APC assignment program designed to meet the mandated OPPS implementation. The software performs the following functions when processing a claim:

* Edits a claim for accuracy using full Outpatient Code Editor (OCE) specifications
   and optional CMS Correct Coding Initiative (CCI) edits
* Assigns APCs
* Assigns CMS-designated service indicators
* Assigns payment indicators
* Computes discounts, if applicable
* Determines the disposition of a claim based on generated edits
* Determines if packaging is applicable
* Determines payment adjustment, if applicable

APCActive™ Pricer DLL  uses the payment indicators from the Code Editor DLL output and computes the APC reimbursement and coinsurance amounts for each line item using the same pricing factors and formulas used by Medicare.  The APCActive™ Pricer DLL will calculate a geographically adjusted APC reimbursement for any Medicare hospital in the U.S.

Data Requirements

The following data elements must be included on a patient record to successfully be processed by the program:

Type of bill	Service date
Statement covers period, from and through dates	Revenue code
Birth date	Service units
Sex	Charges
Condition codes	Medicare provider number (NPI or OSCAR)
HCPCS/CPT procedure code(s) and modifier(s)	ICD-9-CM diagnosis code(s)

APCActive™ Outpatient PPS (OPPS) Components are an ideal solution for claims processing applications, data warehousing and data analysis, claim review, compliance auditing, repricing applications and more.

The APCActive™ Pricer DLL calculates the reimbursement amounts using the same formulas and provider-specific factors as Medicare. Some small variation may occur and is attributable to rounding error of the computing platform. Accuracy also varies with the currency of the hospital specific factors being used in the computation, as Medicare can make updates at any time. New Medicare requirements and payment formula changes may affect the accuracy of the APCActive™ estimated reimbursement.