Ambulatory Payment Classification
The Medicare grouping system that determines hospital outpatient payment amounts under OPPS, analogous to MS-DRGs for inpatient.
Definition
Ambulatory Payment Classifications (APCs) are the unit of payment under the Medicare Hospital Outpatient Prospective Payment System (OPPS), established by the Balanced Budget Act of 1997 and effective August 2000. CMS groups outpatient procedures with similar clinical characteristics and resource use into APCs and pays a single bundled amount per APC, with status indicators that determine whether the service is separately payable, packaged into another APC, or excluded.What this means in practice
APC assignment plus pass-through status (TPT) determines the outpatient economics of a new device. Many MedTech launch strategies hinge on securing a favorable APC and, where eligible, transitional pass-through payment.- •Assuming an inpatient NTAP equivalent exists in OPPS, it does not; the outpatient analog is TPT.
- •Missing the annual OPPS comment window (June-September) for APC reassignment requests.
Related terms
Grouped by themeEditor's picks
· Hand-selected related conceptsMedicare's payment system for inpatient hospital stays.
Medicare's inpatient hospital payment classification system.
Supplemental Medicare payment for inpatient use of qualifying new technologies.
Medicare's payment system for hospital outpatient services.
More in Reimbursement
· Same categorySupplemental outpatient payment for new device technologies.
Federal program providing discounted drugs to safety-net providers.
Migration of procedures from hospitals to ambulatory surgery centers.
Financial model that estimates the total cost consequences of adopting a new technology to a payer's budget over a defined horizon.
Primary references
3 sources- 1
CMS, Hospital OPPSVerifiedCMScms.gov
- 2
42 CFR 419VerifiedeCFRecfr.gov
- 3
AMA CPT ResourcesVerifiedAMAama-assn.org
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