Similar cases with different outcomes

[Shiningrock]

I'm working on some outpatient cases and I'm seeing a discrepancy with the grouping logic. There are two cases which are under apc 5193 via c9600 (primary) and the secondary hcpcs codes were 93458 for the first case and 93458/92978 for the second one. With addendum D in mind, I though both would quality for complexity adjustment, but only the first one did. Anyone experienced something like this to explain this?

 

[Billie.F]

Both your cases look like they should trigger the complexity adjustment under the composite APC rules, especially with 92978 tagging along. What might be messing it up is how the code sequencing or packaging is handled in the claims processing system, maybe even minor differences in how the modifiers or dates are submitted will throw off the adjustment.

 

[HAYABUSA]

I'm working on some outpatient cases and I'm seeing a discrepancy with the grouping logic. There are two cases which are under apc 5193 via c9600 (primary) and the secondary hcpcs codes were 93458 for the first case and 93458/92978 for the second one. With addendum D in mind, I though both would quality for complexity adjustment, but only the first one did. Anyone experienced something like this to explain this?

Ok... it might be that the 92978 got flagged as a packaged service in that combo. So it affected the complexity bump. CMS logic isn't always logical.

 

[sammywammy]

I'm working on some outpatient cases and I'm seeing a discrepancy with the grouping logic. There are two cases which are under apc 5193 via c9600 (primary) and the secondary hcpcs codes were 93458 for the first case and 93458/92978 for the second one. With addendum D in mind, I though both would quality for complexity adjustment, but only the first one did. Anyone experienced something like this to explain this?

I've run into that previously. Sometimes, it's the combination logic in OPPS that blocks the adjustment when certain codes stack unusually like 92978 can throw it off depending on sequencing. Just double check how your encoder is reading the hierarchy. Or confirm with them or something.