What are Comprehensive APCs?

Comprehensive APCs, aka C-APCs, are much like DRGs but on the Outpatient side. Comprehensive APCs expand CMS’s intentions of the Outpatient Prospective Payment System (OPPS) being a partially packaged system.  

The official definition is:

“A classification for the provision of a primary service and all adjunctive services provided to support the delivery of the primary service.”

C-APCs are identified by HCPCS with assigned status indicator = J1 or J2.  All covered services on the claim are packaged with the primary J1,J2service.  CY 2020 includes 2,977 HCPCS codes assigned J1 or J2 status and therefore, triggering a single claim payment.  All those HCPCS are placed into C-APCs based on clinical family.

This is the history of C-APCs. They began in 2015 with 25 C-APCs involved. Today, there are 67 C-APCs that are part of the OPPS.

History of C-APCs 

Services typically additional to the primary service and provided during the delivery of 

the comprehensive service (and NOT paid separately) include:

  • Diagnostic procedures
  • Laboratory tests
  • Other diagnostic tests & treatments that assist in the delivery of the primary procedure
  • Visits & evaluations performed in association with the procedure
  • Un-coded services and supplies used during the service
  • DME, prosthetic/orthotic items and supplies, when provided as part of the outpatient service
  • Any other HCPCS code representing services given during the complete comprehensive service

Some services are excluded from the packaging into a single payment. The following are NOTincluded in the C-APC payment and ARE paid separately:

  • Corneal Tissue (status indicator = F)
  • Pass-Through Drugs and Biologicals (status indicator = G)
  • Pass-Through Devices (status indicator = H)
  • Influenza & Pneumococcal Pneumonia Vaccines (status indicator = L)
  • Brachytherapy Sources (status indicator = U)
  • Ambulance 
  • Mammography (diagnostic & screening)
  • Rehabilitation Therapy
  • New Technology
  • Self-administered drugs
  • All Preventative services

Based on CMS All US volumes, the most reported top 5 C-APCs (out of 67) Nationally over recent years include (listed in order of most frequently reported):

REMEMBER: OPPS is not a simple fee schedule – something to really think about when using as a guide for pricing strategy!

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Sometimes ComprehensiveAPCs may get confused with CompositeAPCs.  Stay tuned for our post coming soon, “What are Composite APCs?”

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