A composite ambulatory payment classification (APC) is when a single payment rate for a service which is a combination of several HCPCS codes on the same date of service (or a different date) for several major procedures.

How does APC pricing work?

The payments are calculated by multiplying the APCs relative weight by the OPPS conversion factor and then there is a minor adjustment for geographic location. The payment is divided into Medicare’s portion and patient co-pay. Co-pays vary between 20 and 40% of the APC payment rate.

What is the difference between CPT and APC codes?

Surgical, significant and ancillary APCs are assigned using only the CPT-4 procedure codes, while medical APCs are based on the combination of the ICD-9-CM diagnosis code and the E&M CPT-4 code. HCFA also considered defining medical APCs based only on diagnosis code or only on E&M code.