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When it comes to the APC grouper logic, I was under the impression that OPPS Addendum B contained the HCPCS to APC crosswalk and Addendum J the 'lift' logic for Complexity Adjusted APC codes. With this assumption in hands, I looked at various cases in our system that 3M coded and recognized unexpected discrepancies. For example: Addendum B put 2 cases into APC group 5193 by ways of C9600 (primary). Based on the listed secondary HCPCS codes (Case A had HCPCS 93458 and Case B 93458 and 92978), I expected both to be complexity adjusted. To my surprise, 3M only lifted Case A to 5194 based on the mentioned HCPCS code.
Are there any exclusion criteria or other variables in the context of APC coding that need to be taken into account that explain the outcome of Case B? Do the modifiers supersede the logic laid out in Addendum J?
Are there any exclusion criteria or other variables in the context of APC coding that need to be taken into account that explain the outcome of Case B? Do the modifiers supersede the logic laid out in Addendum J?
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