This field contains one of two potential pieces of data; the Ambulatory Payment Classification (APC) code or the Health Insurance Prospective Payment System (HIPPS) code, which corresponds with the revenue center line for the claim.
The APC codes are used as the basis for payment for outpatient prospective payment (OPPS) service (e.g., Part B institutional).
Some Part A claim types (e.g., home health and SNF) use resource groupings, which are similar to case-mix groups, as the basis for payment (e.g., HHRG, SNF RUGs).
For home health (HH) claims, when the revenue center code (variable called REV_CNTR) is 0023, the HHRG is located in this field and is a HIPPS code. This field is only meaningful for a HH claim when CMS determines the claim should be paid using a different HIPPS code than the one submitted by the provider. When this happens, the revised HIPPS code (the one actually used for payment purposes) appears in this field and the original HIPPS code submitted by the provider remains in the HCPCS_CD field. Otherwise, this variable will always be null or have a value of “00000” for HH revenue center records.
The resource utilization group for the particular revenue center is located in the data field called the APC or HIPPS code variable.
The APC is a four byte field.
The HIPPS code is a five byte field (such as 1AFKS).
The APC field is populated for those claims that are required to process through Outpatient PPS Pricer.
The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with a condition code '07' and certain HCPCS. These claim types could have lines that are not required to price under OPPS rules so those lines would not have data in this field.