Hospital Outpatient Reimbursement

Outpatient facility claims also report CPT® and HCPCS6 codes, which map to Ambulatory Payment Classifications (APCs), which assign a Medicare hospital outpatient payment rate for the service. Depending upon the services provided, hospitals may receive payment for more than one APC per patient encounter. If a claim contains services that result in an APC payment but also contains packaged services, no separate payment for the packaged services will be provided, as these are included in the APC. However, charges related to the packaged services are used for outlier and Transitional Corridor Payments (TOPs) as well as for future rate setting. Therefore, it is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT® and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately or is packaged.

The C-codes below are reported by outpatient facilities for cases that involve drug-eluting stents. Please note that coronary interventions of additional branches are bundled procedures, which will not be reimbursed under the Medicare physician fee schedule or the HOPPS payment methodology.

Procedure Codes and Physician Reimbursement for Coronary Procedures

APC	Description	Status Indicator	2017 Relative Weight	2017 Medicare Base Payment Rate
Diagnostic Procedures and Imaging
5181	Level 1 Vascular Procedures (code 93503)	T	9.1177	$684
5182	Level 2 Vascular Procedures (code 93505)	T	31.4609	$2,360
5188	Diagnostic Cardiac Catheterization (codes 93451-93461, 93530- 93533)	J1	37.7643	$2,832
5192	Level 2 Endovascular Procedures (code 92920)	J1	64.3080	$4,823
5193	Level 2 Endovascular Procedures (code 92920)	J1	64.3080	$9,748
5194	Level 3 Endovascular Procedures (codes 92924, 92928, 92937, 92941, 92943, C9600, C9604)	J1	129.9758	$14,776
5694	Level 4 Drug Administration (code 92977)	T	3.7243	$279

Code	Description	APC
C9600	Drug eluting stent, single vessel	5193
+C9601	Drug eluting stent, additional branch	Bundled
C9602	Atherectomy + drug eluting stent, single vesse	5194
+C9603	Atherectomy + drug eluting stent, additional branch	Bundled
C9604	PCI of or through bypass, any method(s), with drug-eluting stent	5193
+C9605	PCI of or through bypass, any method(s), with drug-eluting stent, additional branch	Bundled
C9606	PCI of acute MI, all interventions, with drug-eluting stent, single vessel	5194
C9607	PCI of chronic total occlusion, any method(s), with drug-eluting stent	5194
+C9608	PCI of chronic total occlusion, any method(s), with drug-eluting stent, additional branch	Bundled

OPPS payment status indicators (SIs) indicate whether a service represented by a HCPCS or CPT® code is payable under the OPPS or another payment system, and also whether particular OPPS policies apply to the code (eg, multiple procedure discounts or other payment reductions, full separate payment, or is a service packaged with another procedure). Relevant OPPS Status Indicators include:

C Inpatient Procedures; not paid under OPPS. 

J1 Comprehensive code: all covered Part B services on the claim are packaged with the primary J1 service for the claim, except services with OPPS SI = F, G, H, L and U; ambulance services; diagnostic and screening mammography; all preventive services; and certain Part B inpatient services. 

N Payment is packaged into payment for other services, including outliers; no separate APC payment. 

T Significant procedure, multiple procedure reduction applies; separate APC payment.