LyticExperienceHospital outpatient settings of care: coverage and reimbursement
This guide includes general descriptions of coding, billing, coverage, and reimbursement matters related to the use of Activase (Alteplase) and is provided for informational purposes only. Please consult Centers for Medicare & Medicaid Services or other payers to verify appropriate codes and learn about payer coverage policies, reimbursement rates, or billing requirements. The submission and completion of reimbursement- or coverage-related documentation are the responsibility of the patient and healthcare provider. Genentech, Inc. and its subsidiaries make no representation or guarantees concerning reimbursement or coverage for any service or item.
The hospital outpatient setting is a setting of care in which medical services are provided by a hospital or other qualified facility to a patient within a 24-hour period (ie, the patient is never admitted) and includes items and services provided by the hospital in the emergency room.
The following provides more detailed information on coverage and reimbursement as it relates to the outpatient setting.
Medicare hospital outpatient payment overview
Medicare pays for items and services provided by the hospital outpatient department through the Hospital Outpatient Prospective Payment System (HOPPS). Under HOPPS, Current Procedural Terminology (CPT®*) and Healthcare Common Procedural Coding System (HCPCS) codes billed by hospitals are assigned to Ambulatory Payment Classifications (APCs).
APCs are not billing codes but rather HOPPS payment groupings categorized by type of item and service provided. The items and services are grouped based on clinical similarity and hospital resource utilization. Each CPT® or HCPCS billing code "maps" to an APC and each APC has its own payment rate. The payment for one Medicare outpatient hospital visit will be the sum of APCs that are associated with the patient's treatment.
APC drug payment rates are set by CMS at average acquisition cost and may vary annually. For 2010, APC payments for drugs used in the Medicare hospital outpatient setting are set at average sales price
Private payers and state Medicaid agencies have different policies regarding coverage and reimbursement for items and services provided to patients in the hospital outpatient setting. Please consult individual payers for more information.
- *
- CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained therein. Applicable FARS/DFARS restrictions apply to government use.
Helpful links
Genentech support
Genentech is neither affiliated with nor endorses any of the following organizations.
Professional organizations
- American Medical Association Current Procedural Terminology payment search
- American Academy of Neurology Supplementary ICD-9 'V-Code'
Government sites
