Ambulatory Visit Classification Systems APGs and APCs

1
Ambulatory Visit Classification Systems APGs
and APCs

• Implications for Payment, Quality of Ambulatory
  Visits or Brief Episodes (Post-Acute Care or
  Month Long Periods) of Chronic Illness

2
Agenda

• Overview of Outpatient Case Mix Concepts/ OPPS
• Ambulatory Patient Groups - V 2.0
• Ambulatory Payment Classification (APC) system
• Use of these systems for cost/quality public
  reporting

3
Overview OPPS

• The major difference between the inpatient PPS
  and the outpatient PPS is that a patient may be
  assigned to multiple APCs, whereas an inpatient
  is always assigned to a single DRG
• The total payment for the visit is computed as
  the sum of the individual payment rates for each
  service, or line item (with discounts and
  restrictions when applicable)
• The key differences between APGs and APCs is that
  the former bundle services into a more aggregated
  set of groups and that they are more clinically
  coherent. APCs are a fee schedule and do not
  provide a basis for cost comparison

4
The Two Severity Adjustments For Ambulatory Visits

• Ambulatory Patient Groups (APGs)
• Ambulatory Payment Classification (APCs)

5
Essential Characteristics Needed For Visit-Based
Ambulatory Classification System

• Be comprehensive
• Be administratively simple
• Be based on a unit of payment that is homogeneous
  in terms of resource use
• Be clinically meaningful
• Provide minimal opportunities for upcoding
• Provide flexibility
• Ensure predictability of expenditures and
  hospital revenue
• Provide incentives for hospital cost control
• Provide management information for hospitals
• Assure beneficiary access to quality care

6
Initial APG Partition Based on the Presence of a
Significant Procedure
7
Medical APGs

• Describe patients who receive medical treatment
  but do not have a significant procedure performed
  during the visit. Medical patients are
  described using the diagnoses of the patient
  coded in ICD-9-CM.

8
Medical APCs

• Types of medical visits
• Low level Clinic visit
• Mid level Clinic visit
• High level Clinic visit
• Low level ER visit
• Mid level ER visit
• High level ER visit

9
Technology APCs Important from a payment point
of view difficult from a public report card
perspective
10
APGs vs APCs Public Reports Charges

• APCs are essentially a fee schedule and dont
  provide information about the visit it depends
  for which visits you want to provide information
  
• . That is, for straightforward surgery it is
  likely that one APC will be generated. For other
  services such as radiation therapy, nuclear
  medicine, services requiring significant devices
  numerous APCs will be generated and the user
  would need to aggregate APCs together to arrive
  at a single number for a public report.

11
Customers of an Outpatient Prospective Payment
System. These Customers Include

• Beneficiaries
• Health facilities
• Employees of health facilities
• Physicians treating Medicare beneficiaries
• Payers

12
Several Data Sources Could Be Used To Provide
Information Useful for These Customers. The
Sources Include

• Claims Data
• Retrospective and prospective clinical studies
  and audits
• Information gleaned from meetings of panels of
  customers (e.g., physicians, hospital
  administrators),
• Information derived from instruments fielded to
  customers. particularly beneficiaries.

13
Claims Data could Track Clinical Quality, In A
Statistical Process Control Manner, From The
Following Types of APG Categories

• Estimating complications among beneficiaries
  undergoing surgical procedures (e.g., admission
  to the hospital following cataract or hernia
  procedures).
• Determining changes in patterns of performance of
  significant procedures over time, which can be
  important indicators of either underuse of
  overuse
• Tracking preventive screening APGs (e.g.,
  mammography, minor gynecological procedures,
  adult well care, immunizations, and so forth)
  could provide information on underuse.

14
Expected Profit or Loss Statement Outpatient
Cardiovascular Product Line
15
Severity Adjusted Ambulatory Visit Significant
Procedure Report
16
Summary of APGs/APCs

• Provides a basis for measuring the cost and
  aspects of quality of visit based ambulatory
  services
• Can be used as the basis for visit based
  reimbursement of facilities and/or physicians
• Can be adapted to use any coding system
• APGs can be used to monitor quality better than
  APCs
• APCs are more widely used than APGs