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1new - APGs APCs Ambulatory Patient Groups Ambulatory...

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APGs & APCs APGs & APCs Ambulatory Patient Groups & Ambulatory Patient Classifications
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What are APCs What are APCs Method used to pay hospitals & ambulatory surgery centers for outpatient services using a prospective payment system (PPS) Providers receive fixed payments for individual services Services assigned to various APC categories
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What are APCs What are APCs APCs developed from Ambulatory Patient Groups (APGs) Amount & type of resources used in an outpatient visit are grouped in APC categories Services in each APC have similar clinical characteristics, resource use, & cost
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What are APCs What are APCs Each APC group assigned a weight value applied to a conversion factor to yield a hospital payment Conversion factor for 1999 = $51.42 Based on 1996 data from claims paid & cost data
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Why APGs Were Developed Why APGs Were Developed To encompass the full range of ambulatory settings i.e. same day surgery units, hospital emergency rooms, outpatient clinics To represent ambulatory patients across the entire patient population To differentiate facility & control costs Variation from RBRVS To focus on primacy of hospital care
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Current vs. Proposed System Current vs. Proposed System Example: current system Total charges = $5,963 Copay (20%) = $1,193 Total MC allowable = $3,578 MC payment (80%) = $2,862 Example: proposed system with outpatient PPS Total charges = $5,963 Copay (20%) = $1,193 Total MC allowable = $3,578 Actual copay (33%) = ($1193) Total MC payment = $2,385
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Current vs. Proposed System Current vs. Proposed System Variance between systems Difference = Proposed (outpatient PPS) - Current = $2,385 - $2,862 = ($477) Increased cost control with proposed system of outpatient PPS
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Cost Reductions With Cost Reductions With Outpatient PPS Outpatient PPS Congressionally mandated 5.8% reduction in amounts payable for hospital operating costs 10% reduction in amounts payable for hospital capital costs Scheduled sunset 9/30/98 Extended through 12/31/99
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Steps in Developing APGs Steps in Developing APGs 1 Choosing initial classification variable DRGs used major diagnostic categories APCs use procedure categories 2 Partition procedures into set of mutually exclusive procedure groups Inpatient only vs. outpatient
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Steps in Developing APGs Steps in Developing APGs 3 Procedures done on ambulatory basis then assigned to a class Significant procedure Constitutes reason for visit Ancillary service procedure Ordered to assist in diagnosis & treatment
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Steps in Developing APGs Steps in Developing APGs 4 Significant Procedure APGs then divided into groups of CPT-4 codes based upon body system associated with the procedure Integumentary system Musculoskeletal system Respiratory system Cardiovascular system Hematologic, lymphatic, & endocrine system
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Steps in Developing APGs Steps in Developing APGs 4 APGs divided based upon body system (cont.) Digestive system Urinary system Male & female genital system Nervous system Eye & ocular adnexa (accessory parts) Facial, ear, nose, mouth, & throat
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