Ambulatory Payment Classification (APC)

Grouper

The DataMetrix Grouper:

• Outpatient facility claims are subjected to a series of edits to identify any demographic (e.g., patient age and gender), and coding irregularities.
• After passing through the edit component, claims are assigned the Ambulatory Payment Classification (APC) number/s and editing information that is used in the APC Pricer.

Pricer

• The DataMetrix Pricer works seamlessly with the DataMetrix Grouper.
• The APC assignments are passed to the Pricer along with editing, pricing, and cost information that is used to determine the payment amount.
• Geographically-specific CMS fee schedules are used for non-APC services. These fee schedules are updated quarterly and applied based on date of service.

Manual Review

Based on DataMetrix proprietary algorithms, suspicious claims are identified for additional review. These claims are reviewed by nurses and certified and experienced coders to identify any reporting irregularities.

Benefits

• Utilizes CMS edits and pricing
• DataMetrix updates all edits, fee schedules and pricing, based on CMS schedules.
• All pricing is determined by date of service and is specific to the facility’s geographic location
• Application of DataMetrix proprietary algorithms to flag suspicious claims for additional review

What makes DataMetrix different?

Our DRG and APC edits identify and investigate:

• Discharge status
• Automated pricing engine not updated timely
• Incorrect DRG/APC version being applied
• Improper interpretations of Medicare website
• Incorrect manual calculations
• Incorrect DRG/APC grouping
• Correct pricing for Medicare Advantage (HMO paid claims)
• Out of date fee schedules
• Post acute transfers
• Late charges
• System defaulted payments

Any and all of these may impact the pricing and accuracy of payments. Our results are documented and explained to the provider. When agreement is reached, and signoff obtained, DataMetrix recovers overspent dollars that come back to the Health Plans.