APC Review

Our experience has shown that, on average, hospitals are not being paid in full for services provided to Medicare beneficiaries under the Outpatient Prospective Payment System (“OPPS”). 

Our APC Review is a combination of 4 services that together provide a complete overview of your facility’s reimbursement performance in the current Medicare environment:  Historical OCE Review, APC Payment Variance Calculation, In-depth Chart Review, and a Charge Description Master Compliance Review.

Historical OCE Review 

• We take up to 3 months of your claims as submitted to Medicare and send them through our state-of-the-art automated coding and compliance system, to evaluate the accuracy of your billing and coding. 

• We provide you with detailed reports of the errors as well as the net financial impact to your facility of the denials/rejected claims.

APC Payment Variance & Shortfall Evaluation 

• We take the clean claims found in the OCE Review and evaluate them for accuracy and completeness of payments as submitted to Medicare.  Our computer system calculates the appropriate APC and returns the expected payment for your specific facility.    

• We provide you with a detailed report of the payment variances.  

In Depth Chart Review 

• We review an appropriate sampling of your ER and Ambulatory Surgery encounters for accuracy of coding for the encounters (E&M Codes in the ER) as well as for the completeness of coding related to additional procedures. 

• All significant coding variances are flagged for discussion with the HIM Management and Coding Staff.  Detailed findings and recommendations are provided in a final report.  

CDM Compliance Review

• We have incorporated all of the applicable OCE/APC edits into our ChargeMASTER expert system.  In addition, the pricing module identifies all charges under the OPPS/APC rate or the clinical fee schedules.  Our OPPS modeling module identifies opportunities to add missing procedure or transitional pass-through codes.  We update our files weekly, as bulletins come out, so our database is always current.  Using our state-of-the-art, web-based interface, we can process your CDM in nano-seconds and deliver the results to you immediately.

Completion of our APC Review takes approximately 4 weeks from receipt of claims samples from your hospital until presentation of our reports.