Reader Question: Relatively Few APCs

Question: How can all the different kinds of outpatient care be classified into just a few hundred ambulatory payment classification (APC) groups?

Maryland Subscriber

Answer: In the original regulations, the Health Care Financing Administration (HCFA) created seven major APCs for medical visit services, three for clinic visits, three for emergency department visits, and one for critical care services. HCFA most likely will use a hybrid of ICD-9 diagnosis codes and CPT codes to determine payment rates for emergency department and clinic visits.

Some 31 CPT codes were assigned to the seven APCs for major medical outpatient services. HCFA collapsed 12,000 ICD-9 codes into 20 major diagnostic categories arranged generally by body systems. This results in a matrix of 121 CPT/diagnosis combinations.

The most costly combination is more than 10 times as expensive as the least costly combination. The APC groupings are based on two criteria: the procedures within each group must be similar clinically, and the resource costs must be similar for grouped procedures.

When the new regulations are released, HCFA may establish more APCs than were included in the original version, but the grouping principal should remain the same.


- Published on 2000-05-01