Viewing as · platform support session
RevAllowPayer reimbursement calculators

APC Outpatient Calculator

Looks up a HCPCS/CPT code's actual Medicare hospital outpatient (OPPS) facility rate — the code's APC relative weight × the CMS conversion factor × your area's wage index — and flags when your own charge is priced below it.

The conversion factor is CMS's real published CY2026 OPPS rate (CMS-1834-FC), and the wage index is real for Oklahoma (statewide) and Texas (rest of state), pulled directly from CMS's FY2026 IPPS wage index file. The HCPCS→APC crosswalk is the full real CY2026 (July) Addendum B — 8,730 codes, covering every code CMS assigns a separate or packaged OPPS payment to. A code not found here genuinely isn't OPPS-APC-priced (or belongs to a later quarter's update this file hasn't picked up yet). Entering a diagnosis checks it against real Local Coverage Determinations (LCDs) for MAC Jurisdiction H (Novitas Solutions, which covers both Oklahoma and Texas) — this is advisory only and never changes the rate shown.
This hospital is set up as a Critical Access Hospital (CAH). Medicare does not pay CAH outpatient claims under the standard OPPS/APC formula at all — it pays 101% of your own estimated cost for each service (your billed charge × this hospital's Medicare cost-to-charge ratio). Every code works here, since no APC crosswalk lookup is needed for this pricing method — just enter your charge per line.

Wage Index Area & Year

Code Lookup

HCPCS / CPT Lookup

or search by name
Enter a HCPCS/CPT code to see its APC assignment and estimated Medicare rate.

Diagnosis (ICD-10) Lookup

or search by name
Enter an ICD-10 code to see its description. This is a general reference lookup — it is not scoped to any one line's LCD the way the per-line Diagnosis field's dropdown is.

Codes to Price

HCPCS/CPTModifierDescriptionAPCUnitsYour charge ($)Diagnosis (ICD-10)
Medicare Rate Comparison
CodeModifierDescriptionAPC Relative weightStatusMedicare rateYour chargeCoverage
Total Medicare allowable
How this prices

Medicare allowable = (APC relative weight × conversion factor) × (labor-related share × wage index + (1 − labor-related share)) × units.

Labor-related share (60% for CY2026) is the portion of the national rate CMS treats as wage-sensitive; the rest is paid at the national rate regardless of area.

Packaging follows CMS's OPPS Addendum D-1 status-indicator rulebook: a status-N code always packages ($0 separately); when the claim has a status-J1 line, the single highest-paying J1 service is this claim's "comprehensive APC" primary service and nearly everything else on the claim packages into it; a status-Q1/Q2 code packages unless the claim also carries a companion S/S1/T/V/X (Q1) or T (Q2) line; a status-Q4 lab test packages unless it's the only line on the claim. Multiple-procedure discounting: among non-packaged status-T lines on the same claim, only the highest-paying one pays in full — every other one pays 50%. Hover a row's status-indicator badge for its plain-English Addendum D-1 definition.

Hospital modifiers — one per line, applied AFTER packaging/multiple-procedure discounting: 73 (discontinued before anesthesia) and 52 (discontinued, no anesthesia planned) pay 50% of the resolved amount; 74 (discontinued after anesthesia/started) pays 100% — all three only apply to significant/surgical procedures (status S, S1, T, J1, or J2). CT (non–NEMA XR-29 equipment) reduces payment 15%, gated to CMS's own listed CT HCPCS ranges; FX (film X-ray) reduces 20% and FY (computed radiography) reduces 10%, applied on your own modifier choice. 59/XE/XS/XP/XU, 50/LT/RT, 76/77, and JG are recorded but don't change payment — NCCI bundling edits, OPPS bilateral reporting (no 150% rule the way MPFS has), repeat-procedure documentation, and the (as of 2023) informational-only 340B flag, respectively. Every priced line shows the exact rule applied underneath it. Not applied to Critical Access Hospital cost-based pricing (nothing for a percentage to multiply against). Citations: CMS Medicare Claims Processing Manual, Chapter 4, §20.6.

Coinsurance is estimated at the standard 20% of the Medicare allowable, assuming your annual Part B deductible is already met.

Coverage checks every diagnosis entered on a line against real Local Coverage Determinations (LCDs) for MAC Jurisdiction H (Novitas Solutions — covers both Oklahoma and Texas). This is advisory only: it never changes the Medicare rate shown. You'll see it flagged before you even calculate — looking up a code that's governed by an LCD shows a warning in the lookup result, and its row in the Codes to Price table shows "LCD Lxxxxx applies" with the Diagnosis field highlighted until you add one. After you calculate, the Coverage column breaks it down per diagnosis: a ✓ green chip for each one that's on the LCD's covered list, a ✗ chip for each one that isn't, a status badge, and a citation line naming the exact LCD (and its linked Local Coverage Article) that justifies the flag — everything you need for an appeal is right there, no hovering required. "No LCD" (the common case) means the code isn't restricted by any LCD. "Diagnosis needed" means an LCD governs the code and none was entered yet. A line reads "Covered" if ANY ONE of its diagnoses matches (standard diagnosis-pointer convention); "Not covered" means none of them do — consider an Advance Beneficiary Notice (ABN) in that case.

This tool does not cap payment at your charge the way the EAPG/DRG calculators do — it reports Medicare's own rate, and flags when your charge is below it. Status indicators J2 (comprehensive-APC complexity adjustment) and Q3 (true composite-APC code-combination packaging) are priced at the full separate rate — this app has no CMS complexity-adjustment/composite-APC table to model them precisely. It also does not model device-intensive/pass-through drug adjustments or the quality-reporting payment reduction.

CAH cost-based payment = your billed charge × this hospital's Medicare cost-to-charge ratio × 101% (42 CFR 413.70) — a Critical Access Hospital is not paid under the OPPS/APC formula at all for outpatient services.

Coinsurance is estimated at the standard 20% of that cost-based payment, assuming your annual Part B deductible is already met.

This estimate uses one blended cost-to-charge ratio for every line, the same simplification this app's Oklahoma Medicaid DRG outlier calculation uses — a real cost report has department-specific ratios (lab, radiology, OR, etc.) that can differ from the blended figure.