AHA Coding Clinic® for HCPCS - 2001 Quarter 1
APCs: Six months and counting! (You're not alone)
BY DANELLE KELLY R.N., CPC, CPC-H D J KELLY & ASSOCIATES, INC. SCHAUMBURG, ILLINOIS Though it has been six months since the implementation of the Outpatient Prospective Payment System (OPPS), the learning curve continues. The implementation has been difficult and continues to be so. Hospitals that tried to be on top of things early on, that had formed APC task forces well in advance of the August 2000 start date, still had to deal with a myriad of billing and coding issues to get claims past both the internal and Medicare OCE edits. Even the facilities that had...
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Article Overview
This article discusses the practical challenges hospitals faced during the early months of OPPS and APC implementation. It covers broad categories of billing, coding, and claims-processing issues, including use of HCFA guidance, outpatient observation reporting, emergency department billing changes, technical corrections, and common edit-related denials. The piece is aimed at hospital coders, billing staff, HIM professionals, and revenue-cycle teams trying to understand why outpatient claims were still being denied and how the new system affected operations.
Why This Topic Matters
It helps readers understand the kinds of operational and claims-processing problems that arose during the transition to OPPS/APCs and why cross-department coordination became important for outpatient billing accuracy.
Article Sections
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Implementation challenges under OPPS
An overview of the early outpatient prospective payment environment and the operational difficulties hospitals encountered during implementation. It addresses denial volume, claim edits, and workflow strain across billing and coding teams.
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Some reasons why...
A summary of several broad factors contributing to ongoing billing and coding confusion. The discussion includes guidance sources, observation billing issues, technical corrections, emergency department billing changes, and other edit-related concerns.
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So what have we learned...
A closing reflection on lessons from the implementation period. It emphasizes coordination among departments and the need for ongoing claims verification and denial management.
What You Will Learn
- How early OPPS implementation affected hospital billing and coding operations
- Which types of administrative guidance and edit issues were creating confusion
- Why outpatient observation and emergency department billing required special attention
- How claim denials and workflow changes affected hospital revenue-cycle processes
- Why collaboration between clinical, billing, and HIM departments was important
Who Should Read This
- Hospital coders
- Outpatient billing staff
- HIM professionals
- Revenue cycle managers
- Compliance staff
- Hospital administrators
Modifiers Discussed
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