Outpatient claims, APCs and ASC rates, explained
Price a claim takes a hospital outpatient claim the way it reads on the UB-04: the type of bill, the hospital, the dates of service and, for each line, the revenue code, HCPCS or CPT code with modifiers, units, charge and service date. The pricing engine gives every line its status indicator and APC, packages lines into a comprehensive APC or into the procedure they support, reduces each further significant procedure by 50%, and screens the lines against the claim edits, with the CARC and RARC a contractor would use.
For reference-based pricing, the payer basis multiplies the Medicare allowed amount by your percentage (150% by default), can cap it at billed charges for the claim or line by line, and shows the savings against billed charges on the priced lines. That arithmetic runs in your browser and is labeled as modeled. Claim details are never put in links or browser storage.
Compare settings looks up one code's APC and status indicator for hospital outpatient payment and its payment indicator for ambulatory surgical centers, applies each setting's labor share to the local wage index, and splits the allowed amount into program payment and patient share. Claim edits mode screens a list of codes for NCCI procedure pairs, medically unlikely units, packaging and add-on codes, and EAPG mode prices a Medicaid outpatient line from your own base rate and weight.
Rates are the CY2026 outpatient rates, October 2026 OPPS release, with the FY2026 wage index. A date of service outside 2026 is still priced at those rates, and the page says so. CY2027 rates start January 1, 2027: see what the CY2027 outpatient and ASC final rule is expected to change.
Questions
Can I price a whole outpatient claim?
Yes. Price a claim takes each line's revenue code, HCPCS or CPT code with modifiers, units, charge and service date, then applies comprehensive APC packaging, the 50% multiple-procedure reduction, conditional packaging and the claim edits, line by line. The total includes the patient's coinsurance.
Which rates apply to my date of service?
The pricer carries the CY2026 outpatient rates (October 2026 OPPS release) and the FY2026 wage index. A date of service outside 2026 is still priced at CY2026 rates, and the page warns you when that happens.
How is the percent-of-Medicare price worked out?
In your browser: the Medicare allowed amount for the claim times your percentage (150% by default), optionally capped at billed charges for the whole claim or line by line. Savings are billed charges on the priced lines minus that plan amount; lines the edits deny and lines paid on another fee schedule are kept out. It is a model, not a plan determination.
Why does the hospital outpatient rate differ from the ASC rate?
The two settings have separate conversion factors and labor shares, so the same procedure is paid at different rates. The difference is shown in dollars and as a ratio.
What does status indicator T mean?
A significant procedure subject to the multiple-procedure reduction: when billed with another T procedure the same day, the lower-paid one is reduced 50%.
Can I price without a hospital?
Yes. Leave the hospital blank to see the national rate, or enter a wage index.