Ambulatory Payment Classification

Hospital-Based Outpatient Clinics The Outpatient Prospective Payment System (OPPS) is the method for compensation for hospital-based outpatient facilities (DHHS, 2000a). With this system, there is a professional component (e.g., for physician providers) and a technical component (e.g., for nonphysician health care professionals) to billing that describes the various contributions of the health care team during the specific patient encounter. Ambulatory Payment Classification (APC) codes are used within this system to describe the type and complexity of the patient visit to the insurance company. When pharmacists provide services within a hospital-based clinic, the compensation for the service goes to the hospital facility instead of directly to the provider. The revenue generated should be able to be tracked internally as to which department or health care professional was involved in the care of the patient (Snella and Sachdev,... 

A counterbalance to the positive roles that pharmacists play is the increase in the amount of time that we spend on reimbursement and payment issues. Pharmacists in ambulatory care play a role in adjudication of third party claims and often bring the news to patients that a drug ordered for them is not covered by their pharmacy benefit. This often places us in conflict with the patient and their physician in a system that is not our creation. The difficult financial condition of many hospifals places the pharmacist in roles of assuring reimbursemenf for pharmaceuticals for both inpatient and ambulatory care. The Ambulatory Payment Classification (APC) system is intricate and terribly complex and pharmacists must be directly involved in some aspect of fhe coding to assure paymenf. These roles do not represent the optimal use of our scarce manpower. 

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