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CMSManualSystemDepartmentofHealth&HumanServices(DHHS)Pub100-04MedicareClaimsProcessingCentersforMedicare&MedicaidServices(CMS)Transmittal1264Date:JUNE8,2007ChangeRequest5617Subject:July2007IntegratedOutpatientCodeEditor(I/OCE)SpecificationsVersion8.
2I.
SUMMARYOFCHANGES:ThisinstructioninformstheFiscalIntermediaries(FIs)andtheFiscalIntermediaryStandardSystem(FISS)oftheintegrationofthenon-OutpatientProspectivePaymentSystem(Non-OPPS)OCEintotheOPPSOCEeffectiveJuly1,2007.
Thisintegrationhasresultedintheroutingofallinstitutionaloutpatientclaims(whichincludesnon-OPPShospitalclaims)throughasingleintegratedOCEeliminatingtheneedtoupdate,install,andmaintaintwoseparateOCEsoftwarepackagesonaquarterlybasis.
ThisintegrationdoesnotchangethecurrentlogicthatisappliedtooutpatientbilltypesthatalreadypassthroughtheOPPSOCEsoftware.
Itmerelyexpandsthesoftwareusagetoincludenon-OPPShospitals.
ThisnewsoftwareproductwillbereferredtoastheIntegratedOCE.
ClaimswithdatesofservicepriortoJuly1,2007shouldberoutedthroughthenon-integratedversionsoftheOCEsoftware(OPPSandnon-OPPSOCEs)thatcoincidewiththeversionsineffectforthedateofserviceontheclaim.
New/RevisedMaterialEffectiveDate:July1,2007ImplementationDate:July2,2007Disclaimerformanualchangesonly:Therevisiondateandtransmittalnumberapplyonlytoreditalicizedmaterial.
Anyothermaterialwaspreviouslypublishedandremainsunchanged.
However,ifthisrevisioncontainsatableofcontents,youwillreceivethenew/revisedinformationonly,andnottheentiretableofcontents.
II.
CHANGESINMANUALINSTRUCTIONS:(N/Aifmanualisnotupdated)R=REVISED,N=NEW,D=DELETEDR/N/DCHAPTER/SECTION/SUBSECTION/TITLEN/AIII.
FUNDING:NoadditionalfundingwillbeprovidedbyCMS;contractoractivitiesaretobecarriedoutwithintheirFY2007operatingbudgets.
IV.
ATTACHMENTS:RecurringUpdateNotification*Unlessotherwisespecified,theeffectivedateisthedateofservice.
Attachment-RecurringUpdateNotificationPub.
100-04Transmittal:1264Date:June8,2007ChangeRequest:5617SUBJECT:July2007IntegratedOutpatientCodeEditor(I/OCE)SpecificationsVersion8.
2EffectiveDate:July1,2007ImplementationDate:July2,2007I.
GENERALINFORMATIONA.
Background:ThisinstructioninformstheFiscalIntermediaries(FIs)andtheFiscalIntermediaryStandardSystem(FISS)oftheintegrationofthenon-OutpatientProspectivePaymentSystem(Non-OPPS)OCEintotheOPPSOCEeffectiveJuly1,2007.
Thisintegrationhasresultedintheroutingofallinstitutionaloutpatientclaims(whichincludesnon-OPPShospitalclaims)throughasingleintegratedOCEeliminatingtheneedtoupdate,install,andmaintaintwoseparateOCEsoftwarepackagesonaquarterlybasis.
ThisintegrationdoesnotchangethecurrentlogicthatisappliedtooutpatientbilltypesthatalreadypassthroughtheOPPSOCEsoftware.
Itmerelyexpandsthesoftwareusagetoincludenon-OPPShospitals.
ThisnewsoftwareproductwillbereferredtoastheIntegratedOCE.
ClaimswithdatesofservicepriortoJuly1,2007shouldberoutedthroughthenon-integratedversionsoftheOCEsoftware(OPPSandnon-OPPSOCEs)thatcoincidewiththeversionsineffectforthedateofserviceontheclaim.
B.
Policy:ThisnotificationprovidestheIntegratedOCEinstructionsandspecificationsthatwillbeutilizedundertheOPPSandNon-OPPSforhospitaloutpatientdepartments,communitymentalhealthcenters,andforallnon-OPPSproviders,andforlimitedserviceswhenprovidedinahomehealthagencynotundertheHomeHealthProspectivePaymentSystemortoahospicepatientforthetreatmentofanon-terminalillness.
II.
BUSINESSREQUIREMENTSTABLEUse"Shall"todenoteamandatoryrequirementNumberRequirementResponsibility(placean"X"ineachapplicablecolumn)A/BMACDMEMACFICARRIERDMERCRHHIShared-SystemMaintainersOTHERFISSMCSVMSCWF5617.
1TheSharedSystemMaintainershallinstalltheIntegratedOCE(I/OCE)intotheirsystems.
XXX5617.
2IntermediariesandRHHI'sshallinformprovidersoftheOPPSOCEchangesfortheIntegratedOCEdetailedinthisrecurringnotification.
XXX5617.
3ContractorsshallinformprovidersoftheNon-OPPSOCEchangesforIntegratedOCEdetailedinthisrecurringchangenotification.
XXIII.
PROVIDEREDUCATIONTABLENumberRequirementResponsibility(placean"X"ineachapplicablecolumn)A/BMACDMEMACFICARRIERDMERCRHHIShared-SystemMaintainersOTHERFISSMCSVMSCWF5617.
4Aprovidereducationarticlerelatedtothisinstructionwillbeavailableathttp://www.
cms.
hhs.
gov/MLNMattersArticles/shortlyaftertheCRisreleased.
Youwillreceivenotificationofthearticlereleaseviatheestablished"MLNMatters"listserv.
Contractorsshallpostthisarticle,oradirectlinktothisarticle,ontheirWebsiteandincludeinformationaboutitinalistservmessagewithin1weekoftheavailabilityoftheprovidereducationarticle.
Inaddition,theprovidereducationarticleshallbeincludedinyournextregularlyscheduledbulletin.
ContractorsarefreetosupplementMLNMattersarticleswithlocalizedinformationthatwouldbenefittheirprovidercommunityinbillingandadministeringtheMedicareprogramcorrectly.
XXXIV.
SUPPORTINGINFORMATIONA.
Foranyrecommendationsandsupportinginformationassociatedwithlistedrequirements,usetheboxbelow:Use"Should"todenotearecommendation.
X-RefRequirementNumberRecommendationsorothersupportinginformation:5344NotificationofanIntegratedOutpatientCodeEditor(OCE)fortheJuly2007ReleaseB.
Forallotherrecommendationsandsupportinginformation,usethespacebelow:V.
CONTACTSPre-ImplementationContact(s):DianaMotsiopoulosatdmotsiopoulos@cms.
hhs.
gov.
,orStuartBarrancoatstuart.
barranco@cms.
hhs.
govForPolicyrelatedquestionscontactMarjorieBaldoatmarjorie.
baldo@cms.
hhs.
govPost-ImplementationContact(s):RegionalOffice(s)ortheCMSOutpatientCodeEditorEmailatOCE_Integration@cms.
hhs.
govVI.
FUNDINGA.
ForFiscalIntermediaries,Carriers,andtheDurableMedicalEquipmentRegionalCarrier(DMERC),useonlyoneofthefollowingstatements:NoadditionalfundingwillbeprovidedbyCMS;contractoractivitiesaretobecarriedoutwithintheirFY2007operatingbudgets.
B.
ForMedicareAdministrativeContractors(MAC):Thecontractorisherebyadvisedthatthisconstitutestechnicaldirectionasdefinedinyourcontract.
CMSdoesnotconstruethisasachangetotheStatementofWork(SOW).
Thecontractorisnotobligatedtoincurcostsinexcessoftheamountsspecifiedinyourcontractunlessanduntilspecificallyauthorizedbythecontractingofficer.
Ifthecontractorconsidersanythingprovided,asdescribedabove,tobeoutsidethecurrentscopeofwork,thecontractorshallwithholdperformanceonthepart(s)inquestionandimmediatelynotifythecontractingofficer,inwritingorbye-mail,andrequestformaldirectionsregardingcontinuedperformancerequirements.
2ATTACHMENTS–AttachmentA-I/OCESpecificationsVersion8.
2AttachmentB-FinalSummaryofDataChangesIntegratedOCECMSSpecifications–V8.
21AttachmentAIntegratedOutpatientCodeEditor(I/OCE)SpecificationsVersion8.
2ThisattachmentcontainsspecificationsissuedfortheJulyI/OCEVersion8.
2.
AllshadedmaterialreflectschangesincorporatedintotheApril2007OPPSandNon-OPPSversions.
IntroductionThis'integrated'OCEprogramprocessesclaimsforalloutpatientinstitutionalprovidersincludinghospitalsthataresubjecttotheOutpatientProspectivePaymentSystem(OPPS)aswellashospitalsthatareNOT(Non-OPPS).
TheFiscalIntermediarywillidentifytheclaimas'OPPS'or'Non-OPPS'bypassingaflagtotheOCEintheclaimrecord,1=OPPS,2=Non-OPPS;ablank,zero,oranyothervalueisdefaultedto1.
ThisversionoftheOCEprocessesclaimsconsistingofmultipledaysofservice.
TheOCEwillperformthreemajorfunctions:Editthedatatoidentifyerrorsandreturnaseriesofeditflags.
AssignanAmbulatoryPaymentClassification(APC)numberforeachservicecoveredunderOPPS,andreturninformationtobeusedasinputtoaPRICERprogram.
AssignanAmbulatorySurgicalCenter(ASC)paymentgroupforservicesonclaimsfromcertainNon-OPPShospitals.
Eachclaimwillberepresentedbyacollectionofdata,whichwillconsistofallnecessarydemographic(header)data,plusallservicesprovided(lineitems).
Itwillbetheuser'sresponsibilitytoorganizeallapplicableservicesintoasingleclaimrecord,andpassthemasaunittotheOCE.
TheOCEonlyfunctionsonasingleclaimanddoesnothaveanycrossclaimcapabilities.
TheOCEwillacceptupto450lineitemsperclaim.
TheOCEsoftwareisresponsiblefororderinglineitemsbydateofservice.
TheOCEnotonlyidentifiesindividualerrorsbutalsoindicateswhatactionsshouldbetakenandthereasonswhytheseactionsarenecessary.
Inordertoaccommodatethisfunctionality,theOCEisstructuredtoreturnlistsofeditnumbers.
Thisstructurefacilitatesthelinkagebetweentheactionsbeingtaken,thereasonsfortheactionsandtheinformationontheclaim(e.
g.
,aspecificdiagnosis)thatcausedtheaction.
Ingeneral,theOCEperformsallfunctionsthatrequirespecificreferencetoHCPCScodes,HCPCSmodifiersandICD-9-CMdiagnosiscodes.
Sincethesecodingsystemsarecomplexandannuallyupdated,thecentralizationofthedirectreferencetothesecodesandmodifiersinasingleprogramwillreduceeffortandreducethechanceofinconsistentprocessing.
ThespanoftimethataclaimrepresentswillbecontrolledbytheFromandThroughdatesthatwillbepartoftheinputheaderinformation.
Iftheclaimspansmorethanonecalendarday,theOCEwillsubdividetheclaimintoseparatedaysforthepurposeofdeterminingdiscountingandmultiplevisitsonthesamecalendarday.
Someeditsaredatedriven.
Forexample,BilateralProcedureisconsideredanerrorifapairofproceduresiscodedwiththesameservicedate,butnotiftheservicedatesaredifferent.
InformationispassedtotheOCEbymeansofacontrolblockofpointers.
Table1containsthestructureoftheOCEcontrolblock.
Theshadedareaseparatesinputfromreturninformation.
Multipleitemsareassumedtobeincontiguouslocations.
IntegratedOCECMSSpecifications–V8.
22PointerNameUB-04FormLocatorNumberSize(bytes)CommentDxptrICD-9-CMdiagnosiscodes70a-c(Pt'srvdx)67(pdx)67A-Q(sdx)Upto166Diagnosiscodesapplytowholeclaimandarenotspecifictoalineitem(leftjustified,blankfilled).
Firstlisteddiagnosisisconsidered'patient'sreasonforvisitdx',seconddiagnosisisconsidered'principaldx'NdxptrCountofthenumberofdiagnosespointedtobyDxptr14BinaryfullwordcountSgptrLineitementries42,44-47Upto450Table2NsgptrCountofthenumberofLineitementriespointedtobySgptr14BinaryfullwordcountFlagptrLineitemactionflagFlagsetbyFIandpassedbyOCEtoPricerUpto4501(SeeTable7)AgeptrNumericageinyears130-124SexptrNumericsexcode11110,1,2(unknown,male,female)DateptrFromandThroughdates(yyyymmdd)628Usedtodeterminemulti-dayclaimCCptrConditioncodes18-28Upto72UsedtoidentifypartialhospitalizationandhospiceclaimsNCCptrCountofthenumberofconditioncodesentered14BinaryfullwordcountBillptrTypeofbill4(Pos2-4)13UsedtoidentifyCMHCandclaimspendingunderOPPS.
ItispresumedthatbilltypehasbeeneditedforvaliditybytheStandardSystembeforetheclaimissenttoOCENPIProvptrNationalprovideridentifier(NPI)56113PassontoPricerOSCARProvptrOSCARMedicareprovidernumber5716PassontoPricerPstatPtrPatientstatus1712UB-92valuesOppsPtrOpps/Non-OPPSflag111=OPPS,2=Non-OPPS(Ablank,zerooranyothervalueisdefaultedto1)OccPtrOccurrencecodes31-34Upto102ForFIuseNOccptrCountofnumberofoccurrencecodes14BinaryfullwordcountDxeditptrDiagnosiseditreturnbufferUpto16Table3CountspecifiedinNdxptrProceditptrProcedureeditreturnbufferUpto450Table3CountspecifiedinNsgptrMdeditptrModifiereditreturnbufferUpto450Table3CountspecifiedinNsgptrDteditptrDateeditreturnbufferUpto450Table3CountspecifiedinNsgptrRceditptrRevenuecodeeditreturnbufferUpto450Table3CountspecifiedinNsgptrAPCptrAPC/ASCreturnbufferUpto450Table7CountspecifiedinNsgptrClaimptrClaimreturnbuffer1Table5WkptrWorkareapointer1512KWorkingstorageallocatedinuserinterfaceWklenptrActuallengthoftheworkareapointedtobyWkptr14BinaryfullwordTable1:OCEControlblockIntegratedOCECMSSpecifications–V8.
23TheinputforeachlineitemcontainstheinformationdescribedinTable2.
FieldUB-04FormLocatorNumberSize(bytes)CommentsHCPCSprocedurecode4415MaybeblankHCPCSmodifier445x210Servicedate4518RequiredforalllinesRevenuecode4214Serviceunits4617Ablankorzerovalueisdefaultedto1Charge47110UsedbyPRICERtodetermineoutlierpaymentsTable2:LineiteminputinformationTherearecurrently77differenteditsintheOCE.
Theoccurrenceofaneditcanresultinoneofsixdifferentdispositions.
ClaimRejectionThereareoneormoreeditspresentthatcausethewholeclaimtoberejected.
Aclaimrejectionmeansthattheprovidercancorrectandresubmittheclaimbutcannotappealtheclaimrejection.
ClaimDenialThereareoneormoreeditspresentthatcausethewholeclaimtobedenied.
Aclaimdenialmeansthattheprovidercannotresubmittheclaimbutcanappealtheclaimdenial.
ClaimReturntoProvider(RTP)Thereareoneormoreeditspresentthatcausethewholeclaimtobereturnedtotheprovider.
Aclaimreturnedtotheprovidermeansthattheprovidercanresubmittheclaimoncetheproblemsarecorrected.
ClaimSuspensionThereareoneormoreeditspresentthatcausethewholeclaimtobesuspended.
Aclaimsuspensionmeansthattheclaimisnotreturnedtotheprovider,butisnotprocessedforpaymentuntiltheFImakesadeterminationorobtainsfurtherinformation.
LineItemRejectionThereareoneormoreeditspresentthatcauseoneormoreindividuallineitemstoberejected.
Alineitemrejectionmeansthattheclaimcanbeprocessedforpaymentwithsomelineitemsrejectedforpayment.
Thelineitemcanbecorrectedandresubmittedbutcannotbeappealed.
LineItemDenialsThereareoneormoreeditspresentthatcauseoneormoreindividuallineitemstobedenied.
Alineitemdenialmeansthattheclaimcanbeprocessedforpaymentwithsomelineitemsdeniedforpayment.
Thelineitemcannotberesubmittedbutcanbeappealed.
IntegratedOCECMSSpecifications–V8.
24IntheinitialreleaseoftheOCE,manyoftheeditshadadispositionofRTPinordertogiveproviderstimetoadapttoOPPS.
InsubsequentreleasesoftheOCE,thedispositionofsomeeditsmaybechangedtoothermoreautomaticdispositionssuchasalineitemdenial.
Asingleclaimcanhaveoneormoreeditsinallsixdispositions.
Six0/1dispositionsarecontainedintheclaimreturnbufferthatindicatethepresenceorabsenceofeditsineachofthesixdispositions.
Inaddition,therearesixlistsofreasonsintheclaimreturnbufferthatcontaintheeditnumbersthatareassociatedwitheachdisposition.
Forexample,iftherewerethreeeditsthatcausedtheclaimtohaveadispositionofreturntoprovider,theeditnumbersofthethreeeditswouldbecontainedintheclaimreturntoproviderreasonlist.
Thereismorespaceallocatedinthereasonliststhanisnecessaryforthecurrenteditsinordertoallowforfutureexpansionofthenumberofedits.
Inadditiontothesixindividualdispositions,thereisalsoanoverallclaimdisposition,whichsummarizesthestatusoftheclaim.
ThefollowingspecialprocessingconditionscurrentlyapplyonlytoOPPSclaims:1)Partialhospitalizationsarepaidonaperdiembasis.
ThereisnoHCPCScodethatspecifiesapartialhospitalizationrelatedservice.
Partialhospitalizationsareidentifiedbymeansofconditioncodes,billtypesandHCPCScodesspecifyingtheindividualservicesthatconstituteapartialhospitalization(SeeAppendixC).
Thus,therearenoinputlineitemsthatdirectlycorrespondtothepartialhospitalizationservice.
InordertoassignthepartialhospitalizationAPCtooneofthelineitems,thepaymentAPCforoneofthelineitemsthatrepresentoneoftheservicesthatcomprisepartialhospitalizationisassignedthepartialhospitalizationAPC.
2)Reimbursementforadayofoutpatientmentalhealthservicesinanon-PHprogramiscappedattheamountofthepartialhospitalperdiem.
Onanon-PHPclaim,theOCEtotalsthepaymentsforallMHserviceswiththesamedateofservice;ifthesumofthepaymentsfortheindividualMHservicesexceedsthepartialhospitalper-diem,theOCEassignsaspecial"DailyMentalHealthService"paymentAPCtooneofthelineitemsthatrepresentMHservices.
ThepackagingflagisturnedonforallotherMHservicesforthatday(SeeappendixC).
ThepaymentratefortheDailyMentalHealthServicesAPCisthesameasthatforthepartialhospitalizationAPC.
3)Foroutpatientswhoundergoinpatient-onlyproceduresonanemergencybasisandwhoexpirebeforetheycanbeadmittedtothehospital,aspecifiedAPCpaymentismadetotheproviderasreimbursementforallservicesonthatday.
ThepresenceofmodifierCAontheinpatient-onlyprocedurelineassignsthespecifiedpaymentAPCandassociatedstatusandpaymentindicatorstotheline.
Thepackagingflagisturnedonforallotherlinesonthatday.
PaymentisonlyallowedforoneprocedurewithmodifierCA.
Ifmultipleinpatient-onlyproceduresaresubmittedwiththemodifier–CA,theclaimisreturnedtotheprovider.
IfmodifierCAissubmittedwithaninpatient-onlyprocedureforapatientwhodidnotexpire(patientstatuscodeisnot20),theclaimisreturnedtotheprovider.
4)Inpatient-onlyproceduresthatareontheseparate-procedurelistarebypassedwhenperformedincidentaltoasurgicalprocedurewithStatusIndicatorT.
Theline(s)withtheinpatient-separateprocedureisrejectedandtheclaimisprocessedaccordingtousualOPPSrules.
5)WhenmultipleoccurrencesofanyAPCthatrepresentsdrugadministrationareassignedinasingleday,modifier-59isrequiredonthecode(s)inordertopermitpaymentformultipleunitsofthatAPC,uptoaspecifiedmaximum;additionalunitsabovethemaximumarepackaged.
Ifmodifier–59isnotused,onlyoneoccurrenceofanydrugadministrationAPCisallowedandanyadditionalunitsarepackaged(seeAppendixI).
(v6.
0–v7.
3only)6)Theuseofadevice,ormultipledevices,isnecessarytotheperformanceofcertainoutpatientprocedures.
Ifanyoftheseproceduresissubmittedwithoutacodefortherequireddevice(s),theclaimisreturnedtotheprovider.
Discontinuedprocedures(indicatedbythepresenceofmodifier52,73or74ontheline)arenotreturnedforamissingdevicecode.
IntegratedOCECMSSpecifications–V8.
25Conversely,somedevicesareallowedonlywithcertainprocedures,whetherornotthespecificdeviceisrequired.
Ifanyofthesedevicesissubmittedwithoutacodeforanallowedprocedure,theclaimisreturnedtotheprovider.
7)Observationsmaybepaidseparatelyifspecificcriteriaaremet;otherwise,theobservationispackagedintootherpayableservicesonthesameday.
(SeeAppendixH).
8)Directadmissionfromaphysician'sofficetoobservationwillbepackagedintoapayableobservation,orintootherSorTprocedureifpresent;otherwise,thedirectadmissionisprocessedasamedicalvisit(seeAppendixH).
9)Insomecircumstances,inorderforMedicaretocorrectlyallocatepaymentforbloodprocessingandstorage,providersarerequiredtosubmittwolineswithdifferentrevenuecodesforthesameservicewhenbloodproductsarebilled.
Onelineisrequiredwithrevenuecode39Xandanidenticalline(sameHCPCS,modifierandunits)withrevenuecode38X(seeAppendixJ).
10)CertainwoundcareservicesmaybepaidanAPCrateorfromthePhysicianFeeSchedule,dependingonthecircumstancesunderwhichtheservicewasprovided.
TheOCEwillchangethestatusindicatorandremovetheAPCassignmentwhenthesecodesaresubmittedwiththerapyrevenuecodesortherapymodifiers.
11)Providersmustappendmodifier'FB'toproceduresthatrepresentimplantationofreplacementdevicesthatareobtainedatno/reducedcosttotheprovider.
Ifthereisanoffsetpaymentamountfortheprocedure,theOCEwillreducetheAPCratebytheoffsetamountbeforedeterminingthehighestrateformultipleorterminatedprocedurediscounting.
Ifthemodifierisusedinappropriately(appendedtoprocedurewithSIotherthanS,T,XorV),theclaimisreturnedtotheprovider.
12)CertainspecialHCPCScodesarealwayspackagedwhentheyappearwithotherservicesthataresubjecttoAPCpayment;however,theymaybeassignedtoanAPCandpaidseparatelyifthereisnootherAPCserviceonthesameday.
TheOCEwillchangetheSIfromQtoNortothepayableSIspecifiedforthecode.
Iftherearemultiplespecialcodesonaday,onlythecodeassignedtotheAPCwiththehighestpaymentratewillbepaid.
13)Submissionofthetraumaresponsecriticalcarecoderequiresthatthetraumarevenuecode(068x)andthecriticalcareE&Mcode(99291)alsobepresentontheclaimforthesamedateofservice.
Otherwise,thetraumaresponsecriticalcarecodewillberejected.
ThefollowingspecialprocessingconditionappliesONLYtoNon-OPPSHOPDclaims:1)Billtypeof83xisconsistentwiththepresenceofanASCprocedureonthebillandacalculatedASCpayment.
TheIntegratedOCEwillassignbilltypeflagstoNon-OPPSHOPDclaims(oppsflag=2)indicatingthatthebilltypeshouldbe83xwhenthereisanASCprocedurecodepresent;and,shouldnotbe83xwhenthereisnoASCprocedurepresent.
Allinstitutionaloutpatientclaims,regardlessoffacilitytype,willgothroughtheIntegratedOutpatientCodeEditor(IOCE);however,notalleditsareperformedforallsitesofserviceortypesofclaim.
AppendixF(a)containsOCEeditsthatapplyforeachbilltypeunderOPPSprocessing;appendixF(b)containsOCEeditsthatapplytoclaimsfromhospitalsnotsubjecttoOPPS.
TheOPPSPRICERwouldcomputethestandardAPCpaymentforalineitemastheproductofthepaymentamountcorrespondingtotheassignedpaymentAPC,thediscountingfactorandthenumberofunitsforalllineitemsforwhichthefollowingistrue:IntegratedOCECMSSpecifications–V8.
26CriteriaforapplyingstandardAPCpaymentcalculationsAPCvalueisnot00000Paymentindictorhasavalueof1or5Packagingflaghasavalueofzeroor3Lineitemdenialorrejectionflagiszeroorthelineitemactionflagis1Lineitemactionflagisnot2,3or4Paymentadjustmentflagiszeroor1PaymentmethodflagiszeroIfpaymentadjustmentsareapplicabletoalineitem(paymentadjustmentflagisnot0or1)thennonstandardcalculationsarenecessarytocomputepaymentforalineitem(SeeAppendixG).
ThelineitemactionflagispassedasinputtotheOCEasameansofallowingtheFItooverridealineitemdenialorrejection(usedbyFItooverrideOCEandhavePRICERcomputepaymentignoringthelineitemrejectionordenial)orallowingtheFItoindicatethatthelineitemshouldbedeniedorrejectedeveniftherearenoOCEeditspresent.
Theactionflagisalsousedforhandlingexternallineitemadjustments.
Forsomesitesofservice(e.
g.
,hospice)onlysomeservicesarepaidunderOPPS.
ThelineitemactionflagalsoimpactsthecomputationofthediscountingfactorinAppendixD.
ThePaymentMethodflagspecifiesforaparticularsiteofservicewhichoftheseservicesarepaidunderOPPS(SeeAppendixE).
OPPSpaymentfortheclaimiscomputedasthesumofthepaymentsforeachlineitemwiththeappropriateconversionfactor,wagerateadjustment,outlieradjustment,etc.
applied.
AppendixKsummarizestheprocessoffillingintheAPCreturnbuffer.
Ifaclaimspansmorethanoneday,theOCEsubdividestheclaimintoseparatedaysforthepurposeofdeterminingdiscountingandmultiplevisitsonthesameday.
Multipledayclaimsaredeterminedbasedoncalendarday.
TheOCEdealswithallmultipledayclaimsissuesbymeansofthereturninformation.
ThePricerdoesnotneedtobeawareoftheissuesassociatedwithmultipledayclaims.
ThePricersimplyappliesthepaymentcomputationasdescribedaboveandtheresultisthetotalOPPSpaymentfortheclaimregardlessofwhethertheclaimwasforasingledayormultipledays.
Ifamultipledayclaimhasasubsetofthedayswithaclaimdenial,RTPorsuspend,thewholeclaimisdenied,RTPorsuspended.
ForthepurposeofdeterminingtheversionoftheOCEtobeused,theFromdateontheheaderinformationisused.
Theeditreturnbuffersconsistofalistoftheeditnumbersthatoccurredforeachdiagnosis,procedure,modifier,dateorrevenuecode.
Forexample,ifa75-year-oldmalehadadiagnosisrelatedtopregnancyitwouldcreateaconflictbetweenthediagnosisandageandsex.
Therefore,thediagnosiseditreturnbufferforthepregnancydiagnosiswouldcontaintheeditnumbers2and3.
Thereismorespaceallocatedintheeditreturnbuffersthanisnecessaryforthecurrenteditsinordertoallowfutureexpansionofthenumberofedits.
TheeditreturnbuffersaredescribedinTable3.
NameBytesNumberValuesDescriptionCommentsDiagnosiseditreturnbuffer380,1-5Three-digitcodespecifyingtheeditsthatappliedtothediagnosis.
Thereisone8x3bufferforeachofupto16diagnoses.
Procedureeditreturnbuffer3300,6,8-9,11-21,28,37-40,42-45,47,49-50,52-64,66-74,76,77Three-digitcodespecifyingtheeditsthatappliedtotheprocedure.
Thereisone30x3bufferforeachofupto450lineitems.
Modifiereditreturnbuffer340,22,75Three-digitcodespecifyingtheeditsthatappliedtothemodifier.
Thereisone4x3bufferforeachofthefivemodifiersforeachofupto450lineitems.
Dateeditreturnbuffer340,23Three-digitcodespecifyingtheeditsthatappliedtolineitemdates.
Thereisone4x3bufferforeachofupto450lineitems.
Revenuecentereditreturnbuffer350,41,48,65Three-digitcodespecifyingtheeditsthatappliedtorevenuecenters.
Thereisone5x3bufferforeachofupto450lineitemsTable3:EditReturnBuffersIntegratedOCECMSSpecifications–V8.
27Eachofthereturnbuffersispositionallyrepresentativeofthesourcethatitcontainsinformationfor,intheorderinwhichthatsourcewaspassedtotheOCE.
Forexample,theseventhdiagnosisreturnbuffercontainsinformationabouttheseventhdiagnosis;thefourthmodifiereditbuffercontainsinformationaboutthemodifiersinthefourthlineitem.
Therearecurrently77differenteditsintheOCE,tenofwhichareinactiveforthecurrentversionoftheprogram.
Eacheditisassignedanumber.
AdescriptionoftheeditsiscontainedinTable4.
IntegratedOCECMSSpecifications–V8.
28Edit#DescriptionNon-OPPSHospitalsDisposition1InvaliddiagnosiscodeYRTP2DiagnosisandageconflictYRTP3DiagnosisandsexconflictYRTP44Medicaresecondarypayoralert(v1.
0-v1.
1)Suspend54E-diagnosiscodecannotbeusedasprincipaldiagnosisYRTP6InvalidprocedurecodeYRTP7Procedureandageconflict(Notactivated)RTP8ProcedureandsexconflictYRTP9Non-coveredforreasonsotherthanstatuteY(NCL)Lineitemdenial10Servicesubmittedfordenial(conditioncode21)Y(new)Claimdenial11ServicesubmittedforFIreview(conditioncode20)Y(new)Suspend12QuestionablecoveredserviceYSuspend13SeparatepaymentforservicesisnotprovidedbyMedicare(v1.
0–v6.
3)Lineitemrejection14CodeindicatesasiteofservicenotincludedinOPPS(v1.
0–v6.
3)ClaimRTP15Serviceunitoutofrangeforprocedure1Y(new)RTP16Multiplebilateralprocedureswithoutmodifier50(seeAppendixA)(v1.
0–v6.
2)RTP17Inappropriatespecificationofbilateralprocedure(seeAppendixA)Y(new)RTP18Inpatientprocedure2Lineitemdenial19MutuallyexclusiveprocedurethatisnotallowedbyNCCIevenifappropriatemodifierispresentLineitemrejection20Code2ofacodepairthatisnotallowedbyNCCIevenifappropriatemodifierispresentLineitemrejection21Medicalvisitonsamedayasatype"T"or"S"procedurewithoutmodifier25(seeAppendixB)Lineitemrejection22InvalidmodifierY(new)RTP23InvaliddateYRTP24DateoutofOCErangeYSuspend25InvalidageYRTP26InvalidsexYRTP27Onlyincidentalservicesreported3Claimrejection28CodenotrecognizedbyMedicare;alternatecodeforsameservicemaybeavailableY(NRL)Lineitemrejection(SeeAppendixCforlogicforedits29-36,and63-64)29Partialhospitalizationservicefornon-mentalhealthdiagnosisRTP30InsufficientservicesondayofpartialhospitalizationSuspend31PartialhospitalizationonsamedayasECTortypeTprocedure(v1.
0–v6.
3)Suspend32Partialhospitalizationclaimspans3orlessdayswithinsufficientservicesonaleastoneofthedaysSuspend33Partialhospitalizationclaimspansmorethan3dayswithinsufficientnumberofdayshavingmentalhealthservicesSuspend34Partialhospitalizationclaimspansmorethan3dayswithinsufficientnumberofdaysmeetingpartialhospitalizationcriteriaSuspend35OnlyMentalHealtheducationandtrainingservicesprovidedRTP36ExtensivementalhealthservicesprovidedondayofECTortypeTprocedure(v1.
0–v6.
3)Suspend37TerminatedbilateralprocedureorterminatedprocedurewithunitsgreaterthanoneRTP38InconsistencybetweenimplanteddeviceoradministeredsubstanceandimplantationorassociatedprocedureRTP39MutuallyexclusiveprocedurethatwouldbeallowedbyNCCIifappropriatemodifierwerepresentLineitemrejection40Code2ofacodepairthatwouldbeallowedbyNCCIifappropriatemodifierwerepresentLineitemrejectionTable4:Descriptionofedits/claimreasons(Part1of2)1Foredit15,unitsforalllineitemswiththesameHCPCSonthesamedayareaddedtogetherforthepurposeofapplyingtheedit.
Ifthetotalunitsexceedsthecode'slimits,theprocedureeditreturnbufferissetforalllineitemsthathavetheHCPCScode.
Ifmodifier91ispresentonalineitemandtheHCPCSisonalistofcodesthatareexempt,theuniteditsarenotapplied.
2Edit18causesallotherlineitemsonthesamedaytobelineitemdeniedwithEdit49(seeAPC/ASCreturnbuffer"Lineitemdenialorrejectflag").
NoothereditsareperformedonanylineswithEdit18or49.
3IfEdit27istriggered,noothereditsareperformedontheclaim.
4Notapplicableforpatient'sreasonforvisitdiagnosisIntegratedOCECMSSpecifications–V8.
29EditDescriptionNon-OPPSHospitalsDisposition41InvalidrevenuecodeY(new)RTP42MultiplemedicalvisitsonsamedaywithsamerevenuecodewithoutconditioncodeG0(seeAppendixB)RTP43TransfusionorbloodproductexchangewithoutspecificationofbloodproductRTP44Observationrevenuecodeonlineitemwithnon-observationHCPCScodeRTP45InpatientseparateproceduresnotpaidLineitemrejection46Partialhospitalizationconditioncode41notapprovedfortypeofbillY*(new)RTP47ServiceisnotseparatelypayableLineitemrejection48RevenuecenterrequiresHCPCSRTP49ServiceonsamedayasinpatientprocedureLineitemdenial50Non-coveredbasedonstatutoryexclusionY(new)Lineitemrejection51Multipleobservationsoverlapintime(Notactivated)RTP52Observationdoesnotmeetminimumhours,qualifyingdiagnoses,and/or'T'procedureconditions(V3.
0-V6.
3)RTP53CodesG0378andG0379onlyallowedwithbilltype13xor85xY*(new)Lineitemrejection54MultiplecodesforthesameserviceYRTP55Non-reportableforsiteofserviceRTP56E/MconditionnotmetandlineitemdateforobscodeG0244isnot12/31or1/1(ActiveV4.
0–V6.
3)RTP57E/MconditionnotmetforseparatelypayableobservationandlineitemdateforcodeG0378is1/1Suspend58G0379onlyallowedwithG0378RTP59ClinicaltrialrequiresdiagnosiscodeV707asotherthanprimarydiagnosisRTP60UseofmodifierCAwithmorethanoneprocedurenotallowedRTP61ServicecanonlybebilledtotheDMERCY(NRL)RTP62CodenotrecognizedbyOPPS;alternatecodeforsameservicemaybeavailableRTP63ThisOTcodeonlybilledonpartialhospitalizationclaims(SeeappendixC)RTP64ATservicenotpayableoutsidethepartialhospitalizationprogram(SeeappendixC)Lineitemrejection65RevenuecodenotrecognizedbyMedicareY(new)Lineitemrejection66CoderequiresmanualpricingSuspend67ServiceprovidedpriortoFDAapprovalY(new)Lineitemrejection68ServiceprovidedpriortodateofNationalCoverageDetermination(NCD)approvalY(new)Lineitemrejection69ServiceprovidedoutsideapprovalperiodY(new)Lineitemrejection70CAmodifierrequirespatientstatuscode20RTP71ClaimlacksrequireddevicecodeRTP72ServicenotbillabletotheFiscalIntermediaryY-NRLRTP73IncorrectbillingofbloodandbloodproductsRTP74Unitsgreaterthanoneforbilateralprocedurebilledwithmodifier50RTP75IncorrectbillingofmodifierFBRTP76Traumaresponsecriticalcarecodewithoutrevenuecode068xandCPT99291Lineitemrejection77ClaimlacksallowedprocedurecodeRTPTable4:Descriptionofedits/claimreasons(Part2of2)*Non-OPPShospitalbilltypesallowedforeditconditionY=editsapplytoNon-OPPShospitalclaims(informationinparenthesesindicatesneweditsandthosesimilartopreviousnon-OPPSedits)IntegratedOCECMSSpecifications–V8.
210TheclaimreturnbufferdescribedinTable5summarizestheeditsthatoccurredontheclaim.
BytesNumberValuesDescriptionClaimprocessedflag110-3,90-Claimprocessed.
1-Claimcouldnotbeprocessed(edits23,24,46a,orinvalidbilltype).
2-Claimcouldnotbeprocessed(claimhasnolineitems).
3-Claimcouldnotbeprocessed(edit10-conditioncode21ispresent).
9-Fatalerror;OCEcannotrun-theenvironmentcannotbesetupasneeded;exitimmediately.
Numoflineitems31nnnInputvaluefromNsgptr,or450,whicheverisless.
Nationalprovideridentifier(NPI)131aaaaaaaaaaaaaTransferredfrominput,forPricer.
OSCARMedicareprovidernumber61aaaaaaTransferredfrominput,forPricer.
Overallclaimdisposition110-50-Noeditspresentonclaim.
1-Onlyeditspresentareforlineitemdenialorrejection.
2-Multiple-dayclaimwithoneormoredaysdeniedorrejected.
3-Claimdenied,rejected,suspendedorreturnedtoprovider,orsingledayclaimwalllineitemsdeniedorrejected,wonlypostpaymentedits.
4-Claimdenied,rejected,suspendedorreturnedtoprovider,orsingledayclaimwalllineitemsdeniedorrejected,wonlypre-paymentedits.
5-Claimdenied,rejected,suspendedorreturnedtoprovider,orsingledayclaimwalllineitemsdeniedorrejected,wbothpost-paymentandpre-paymentedits.
Claimrejectiondisposition110-20-Claimnotrejected.
1-Thereareoneormoreeditspresentthatcausetheclaimtoberejected.
2-Thereareoneormoreeditspresentthatcauseoneormoredaysofamultiple-dayclaimtoberejected.
Claimdenialdisposition110-20-Claimnotdenied.
1-Thereareoneormoreeditspresentthatcausetheclaimtobedenied.
2-Thereareoneormoreeditspresentthatcauseoneormoredaysofamultiple-dayclaimtobedenied,orsingledayclaimwithalllinesdenied(edit18only).
Claimreturnedtoproviderdisposition110-10-Claimnotreturnedtoprovider.
1-Thereareoneormoreeditspresentthatcausetheclaimtobereturnedtoprovider.
Claimsuspensiondisposition110-10-Claimnotsuspended.
1-Thereareoneormoreeditspresentthatcausetheclaimtobesuspended.
Lineitemrejectiondisposition110-10-Therearenolineitemrejections.
1-Thereareoneormoreeditspresentthatcauseoneormorelineitemstoberejected.
Lineitemdenialdisposition110-10-Therearenolineitemdenials.
1-Thereareoneormoreeditspresentthatcauseoneormorelineitemstobedenied.
Claimrejectionreasons3427Three-digitcodespecifyingedits(SeeTable6)thatcausedtheclaimtoberejected.
Thereiscurrentlyoneeditthatcausesaclaimtoberejected.
Claimdenialreasons3810,Three-digitcodespecifyingedits(seeTable6)thatcausedtheclaimtobedenied.
Thereiscurrentlyoneactiveeditthatcausesaclaimtobedenied.
Claimreturnedtoproviderreasons3301-3,5-6,8,14-17,22-23,25-26,29,35,37-38,41-44,46,48,52,54,55,56,58-63,70-75,77Three-digitcodespecifyingedits(seeTable6)thatcausedtheclaimtobereturnedtoprovider.
Thereare41editsthatcouldcauseaclaimtobereturnedtoprovider.
Claimsuspensionreasons3164,11,12,24,30-34,36,57,66Three-digitcodespecifyingtheeditsthatcausedtheclaimtobesuspended(seeTable6).
Thereare12editsthatcouldcauseaclaimtobesuspended.
Lineitemrejectionreasons31213,19,20,21,28,39,40,45,47,50,53,64,65,67-69,76Three-digitcodespecifyingtheeditsthatcausedthelineitemtoberejected(SeeTable6).
Thereare17editsthatcouldcausealineitemtoberejected.
Lineitemdeniedreasons369,18,49Three-digitcodespecifyingtheeditsthatcausedthelineitemtobedenied(seeTable6).
Therearecurrently3activeeditsthatcausealineitemdenial.
APC/ASCreturnbufferflag110-10-NoservicespaidunderOPPS.
APC/ASCreturnbufferfilledinwithdefaultvaluesandASCgroupnumber(SeeAppF).
1-OneormoreservicespaidunderOPPS.
APC/ASCreturnbufferfilledinwithAPC.
VersionUsed81yy.
vv.
rrVersionIDoftheversionusedforprocessingtheclaim(e.
g.
,2.
1.
0).
PatientStatus21Patientstatuscode-transferredfrominput.
OppsFlag111-2OPPS/Non-OPPSflag-transferredfrominput.
Non-OPPSbilltypeflag111-2AssignedbyOCEbasedonpresence/absenceofASCcode1=Billtypeshouldbe83x2=Billtypeshouldnotbe83xTable5:ClaimReturnBufferaEdit46terminatesprocessingonlyforthosebilltypeswherenoothereditsareapplied(SeeApp.
F).
IntegratedOCECMSSpecifications–V8.
211Table6summarizestheeditreturnbuffers,claimdispositionandclaimreasons.
Table6alsosummarizesthepreandpostpaymentstatusofeachedit.
IntegratedOCECMSSpecifications–V8.
212Table6:RelationshipbetweenEdits,DispositionandReasons(part1of2)Daydenialorrejectionmeansthatalllineitemsoccurringonthedayofthedaydenialorrejectionwillhavethelineitemdenialorrejectionindicator(Table7)setto1.
EditBuffers(seeTable3)ClaimDisposition(seeTable5)ClaimReason(seeTable4)EditOccursonMulti-dayClaimDXProcModLineItemDateRevCodeDenyRejectRTPSuspLineItemDenialLineItemRejectDenyRejectRTPSuspLineItemDenialLineItemRejectRTPWholeClaimSuspWholeClaimRejectorDenyClaimRejectDayDenyorRejectDay*Pre/PostStatus1111YesPre2212YesPre3313YesPre444Post5515YesPre6616YesPre7717YesPre8818YesPre9919Pre10110YesPre1111111YesPre1212112YesPre1313113Pre1414114YesPre1515115YesPre1616116YesPre1717117YesPre1818118YesYesPre1919119Pre2020120Pre2121121Pre2222122YesPre2323123YesPre24124YesPre25125YesPre26126YesPre27127YesPre2828128Pre29129YesPre30130YesPre31131YesPre32132YesPre33133YesPre34134YesPre35135YesPre36136YesPre3737137YesPre3838138YesPreIntegratedOCECMSSpecifications–V8.
213Table6:RelationshipbetweenEdits,DispositionandReasons(part2of2)*Daydenialorrejectionmeansthatalllineitemsoccurringonthedayofthedaydenialorrejectionwillhavethelineitemdenialorrejectionindicator(Table7)setto1.
EditBuffers(seeTable3)ClaimDisposition(seeTable5)ClaimReason(seeTable4)EditOccursonMulti-dayClaimDXProcModLineItemDateRevCodeDenyRejectRTPSuspLineItemDenialLineItemRejectDenyRejectRTPSuspLineItemDenialLineItemRejectRTPWholeClaimSuspWholeClaimRejectorDenyClaimRejectDayDenyorRejectDay*Pre/PostStatus3939139Pre4040140Pre4141141YesPre4242142YesPre4343143YesPre4444144YesPre4545145Pre46146YesPre4747147Pre4848148YesPre4949149YesPre5050150Pre5151151YesPre5252152YesPre5353153Pre5454154YesPre5555155YesPre5656156YesPre5757157YesPre5858158YesPre5959159YesPre6060160YesPre6161161YesPre6262162YesPre6363163YesPre6464164Pre6565165Pre6666166YesPre6767167Pre6868168Pre6969169Pre70170YesPre7171171YesPre7272172YesPre7373173YesPre7474174YesPre7575175YesPre7676176Pre7777177YesPreIntegratedOCECMSSpecifications–V8.
214Table7describestheAPC/ASCreturnbuffer.
TheAPC/ASCreturnbuffercontainstheAPCforeachlineitemalongwiththerelevantinformationforcomputingOPPSpaymentforOPPShospitalclaims.
TwoAPCnumbersarereturnedintheAPC/ASCfields:HCPCSAPCandpaymentAPC.
Exceptwhenspecifiedotherwise(e.
g.
,partialhospitalization,mentalhealth,observationlogic,etc.
),theHCPCSAPCandthepaymentAPCarealwaysthesame.
TheAPC/ASCreturnbuffercontainstheinformationthatwillbepassedtotheOPPSPRICER.
TheAPCisonlyreturnedforclaimsfromHOPDsthataresubjecttoOPPS,andforthespecialconditionsspecifiedinAppendixF-a.
TheAPC/ASCreturnbufferalsocontainstheASCpaymentgroupsforproceduresoncertainNon-OPPShospitalclaims.
TheASCgroupnumberisreturnedinthepaymentAPC/ASCfield,theHCPCSASCfieldiszero-filled.
Table7:APC/ASCReturnBuffer(Part1of2)Size(bytes)ValuesDescriptionHCPCSprocedurecode5AlphaForpotentialfutureusebyPricer.
TransferfrominputPaymentAPC/ASC500001-nnnnnAPCusedtodeterminepayment.
IfnoAPCassignedtolineitem,thevalue00000isassigned.
Forpartialhospitalizationandsomeinpatient-onlyprocedureclaimsthepaymentAPCmaybedifferentthantheAPCassignedtotheHCPCScode.
ASCgroupfortheHCPCScode.
HCPCSAPC500001-nnnnnAPCassignedtoHCPCScodeStatusindicator2Alpha[Rightjustified,blankfilled]A-ServicesnotpaidunderOPPSB-Non-alloweditemorserviceforOPPSC-InpatientprocedureE-Non-alloweditemorserviceF-Cornealtissueacquisition;certainCRNAservicesandhepatitisBvaccinesG-Drug/BiologicalPass-throughH–Pass-throughdevicecategories,brachytherapysources,andradiopharmaceuticalagentsJ-Newdrugornewbiologicalpass-through1K-Nonpass-throughdrugsandbiologicalsL–Flu/PPVvaccinesM–ServicenotbillabletotheFIN-PackagedincidentalserviceP-PartialhospitalizationserviceQ-PackagedservicessubjecttoseparatepaymentbasedoncriteriaS-SignificantprocedurenotsubjecttomultipleprocedurediscountingT-SignificantproceduresubjecttomultipleprocedurediscountingV-MedicalvisittoclinicoremergencydepartmentW–InvalidHCPCSorInvalidrevenuecodewithblankHCPCSX-AncillaryserviceY–Non-implantableDME,TherapeuticShoesZ–ValidrevenuewithblankHCPCSandnootherSIassignedPaymentindicator2Numeric(1-nn)[Rightjustified,blankfilled].
1-PaidstandardhospitalOPPSamount(statusindicatorsK,S,T,V,X)2-ServicesnotpaidunderOPPS(statusindicatorA)3-Notpaid(Q,M,W,Y,E),ornotpaidunderOPPS(B,C,Z)4-Paidatreasonablecost(statusindicatorF,L)5–Paidstandardamountforpass-throughdrugorbiological(statusindicatorG)6–Paymentbasedonchargeadjustedtocost(statusindicatorH)7–Additionalpaymentfornewdrugornewbiological(statusindicatorJ)8-Paidpartialhospitalizationperdiem(statusindicatorP)9-Noadditionalpayment,paymentincludedinlineitemswithAPCs(statusindicatorN,ornoHCPCScodeandcertainrevenuecodes,orHCPCScodesG0176(activitytherapy),G0129(occupationaltherapy),orG0177(patienteducationandtrainingservice))Discountingformulanumber11-8SeeAppendixDforvaluesLineitemdenialorrejectionflag10-20-Lineitemnotdeniedorrejected1-Lineitemdeniedorrejected(editreturnbufferforlineitemcontainsa9,13,18,19,20,21,28,39,40,45,47,49,50,53,64,65,67,68,69,76)2-Thelineisnotdeniedorrejected,butoccursonadaythathasbeendeniedorrejected(notusedasof4/1/02-v3.
0).
Packagingflag10-40-Notpackaged1–Packagedservice(statusindicatorN,ornoHCPCScodeandcertainrevenuecodes)2–Packagedaspartofpartialhospitalperdiemordailymentalhealthserviceperdiem3–Artificialchargesforsurgicalprocedure(submittedchargesforsurgicalHCPCS=10/1/xxgDeleteTOB24Xeffective10/1/05hApplyCCIeditstoTOB22x,23x,34x,74xand75x,effective1/1/06jApplyedit28,effective10/1/05dBypassedit48ifRevenuecodeis100x,210x,310x,0905,0906,0907;0500,0509,0583,0660-0663,0669,0931,0932;0521,0522,0524,0525,0527,0528IntegratedOCECMSSpecifications–V8.
22612x,14xcc4112513xcc4134YesNoYesNoYesYesNo34xVaccine,Antigen,Splint,Cast67YesYesNoNo76xYes875xwithVaccine[v1-6.
3]Yes1071x,73xYes11CC07wantigen,Splint,castYes1275xYes1322x,23x,24xYes1432x,33xYes1572xYes1674xYes1781x,82xYesNoNoNoNoNoNoNoNoNoNo943xYesNoAppendixF(a)FlowChart[OPPSflag=1]IntegratedOCECMSSpecifications–V8.
227AppendixF(b)-OCEEditsAppliedbyNon-OPPSHospitalBillType[OPPSflag=2]FLOWCHARTCELL(*)Provider/BillTypesDx[1-3,5]Proc[8,9,11,12,50,53c,54,69]HCPC[6]NonMcare[28]Proc&Modifier[18]HCPCReq'd[48d]Modifier[17,b22]CCI[19,20,39,40]Units[15]aLineItemDate[23]RevCode[41,65]Age,Sex[25,26]PartialHosp[29-34]APC[21,27,42]MH[35,63,64]BillType[46]APC/ASCbuffercompletedFDA/NCD[67,68]OppsProc(55)DME(61);NotFI(72)112x&14xwcondcode41/OPPSflag=2NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNo212x&14xw.
ocondcode41/OPPSflag=2YesYesYesYesNoNoYesNoYesYesYesYesNoNoNoNoNoYesNoYes313xwconditioncode41/OPPSflag=2YesYesYesYesNoNoYesNoYesYesYesYesNoNoNoNoNoYesNoYes413xw.
ocondcode41/OPPSflag=2YesYesYesYesNoNoYesNoYesYesYesYesNoNoNoNoNoYesNoYes585x/OPPsflag=2YesYesYesYesNoNoYesNoYesYesYesYesNoNoNoNoNoYesNoYesd683x/OPPsflag=2YesYesYesYesNoNoYesNoYesYesYesYesNoNoNoNoYesYesNoYes(*)FLOWCHARTCELLSAREINHIERARCHICALORDERYes=editsapply,No=editsdonotapplyEdit10,andEdits23and24forFrom/Throughdates,arenotdependentonAppxFaifedit23isnotapplied,thelowestservice(orFrom)dateissubstitutedforinvaliddates,andprocessingcontinues.
bBypassedit22ifRevenuecodeis540cEdit53isnotapplicabletobilltype13xor85xdBypassedit72ifTOBis85xandrevenuecodeis096x,097xor098xIntegratedOCECMSSpecifications–V8.
228AppendixG[OPPSOnly]Thepaymentadjustmentflagforalineitemissetbasedonthecriteriainthefollowingchart:CriteriaPaymentAdjustmentFlagValueStatusindicatorG1StatusindicatorH2StatusindicatorJ13Codeisflaggedas'deductiblenotapplicable'4BloodproductwithmodifierBLonRC38Xline25BloodproductwithmodifierBLonRC39Xline26Itemprovidedwithoutcosttoprovider7Allothers01StatusindicatorJwasreplacedbystatusindicatorGstartinginApril2002(V3.
0)2SeeAppendixJforassignmentlogic(v6.
2)IntegratedOCECMSSpecifications–V8.
229AppendixH[OPPSOnly]OCEObservationCriteriaRules:1.
CodeG0378isusedtoidentifyalloutpatientobservations,regardlessofthereasonforobservation(diagnosis)orthedurationoftheservice.
2.
CodeG0379isusedtoidentifydirectadmissionfromaphysician'sofficetoobservationcare,regardlessofthereasonforobservation.
3.
CodeG0378hasdefaultStatusIndicator"Q"anddefaultAPC0a.
Ifthecriteriaaremetforpayableobservation,theSIischangedto"S"andAPC339isassigned.
b.
Ifthecriteriaforpayableobservationarenotmet,theSIischangedto"N".
4.
CodeG0379hasdefaultStatusIndicator"Q"anddefaultAPC0a.
Ifassociatedwithapayableobservation(payableG0378presentonthesameday),theSIforG0379ischangedto"N".
b.
Iftheobservationonthesamedayisnotpayable,theSIischangedto"V"andAPC604isassigned.
c.
IfthereisnoG0378onthesameday,theclaimisreturnedtotheprovider.
5.
Observationlogicisperformedonlyforclaimswithbilltype13x,withorwithoutconditioncode41.
6.
LineswithG0378andG0379arerejectedifthebilltypeisnot13x,or85x.
7.
Ifanyofthecriteriaforseparatelypayableobservationisnotmet,theobservationispackaged,ortheclaimorlineissuspendedorrejectedaccordingtothedispositionoftheobservationedits.
8.
Inordertoqualifyforseparatepayment,eachobservationmustbepairedwithauniqueE/Morcriticalcarea.
(C/C)visit,orwithcodeG0379(Directadmissionfromphysician'soffice).
E/MorC/Cvisitisrequiredthedaybeforeordayofobservation;Directadmissionisrequiredonthedayofobservation.
9.
IfanobservationcannotbepairedwithanE/MorC/CvisitorDirectadmission,theobservationispackaged.
10.
E/MorC/CvisitorDirectadmissiononthesamedayasobservationtakesprecedenceoverE/MorC/Cvisitonthedaybeforeobservation.
11.
E/M,C/CvisitorDirectadmissionthathavebeendeniedorrejected,eitherexternallyorbyOCEedits,areignored.
12.
BoththeassociatedE/MorC/Cvisit(APCs604-616,617)andobservationarepaidseparatelyifthecriteriaaremetforseparatelypayableobservation.
13.
Ifa"T"procedureoccursonthedayoforthedaybeforeobservation,theobservationispackaged.
14.
Multipleobservationsonaclaimarepaidseparatelyiftherequiredcriteriaaremetforeachone.
15.
IftherearemultipleobservationswithinthesametimeperiodandonlyonemeetsthecriteriaforseparateAPCpayment,theobservationwiththemosthoursisconsideredtohavemetthecriteria,andtheotherobservationswillbepackaged.
16.
Observationdateisassumedtobethedateadmittedforobservation.
17.
Thediagnoses(patient'sreasonforvisitorprincipal)requiredfortheseparatelypayableobservationcriteriaare:IntegratedOCECMSSpecifications–V8.
230ChestPainAsthmaCHF4110,1,81,8949301,02,11,12,21,22,91,9239184130,1,93989178605,50,51,52,5940201,11,9140401,03,11,13,91,934280,1,9,20-23,30-33,40-4318.
TheAPCsrequiredfortheobservationcriteriatoidentifyE/MorC/Cvisitsare604-616,617.
IntegratedOCECMSSpecifications–V8.
231AppendixH(cont'd)OCEObservationCriteriaBillType13xHours/Units>=8E/MorC/CvisitonsamedayordaybeforeORG0379presentonsameday**QualifyingAdxorPdxSI=TnotpresentonsamedayordaybeforeAssignAPC339,SI=S,PI=1,packagingflag=0,linedenialrejectionindicator=0,paymentadjustmentflag=0;discountfactor=1ToG0378AssignAPC0,SI=N;PI=9packagingflag=1,lineitemdenialrejectionflag=0,paymentadjustmentflag=0,discountfactor=1toG0378YesYesYesYesYesNoNoNoNoNoG0378presentYes**notalreadypairedwithanotherG0378LineItemRejection(Edit53)G0378DOS1/1SuspendClaim(Edit57)YesNoIntegratedOCECMSSpecifications–V8.
232AppendixH(cont'd)DirectAdmissionLogicG0379presentBillType13xG0378presentonsamedayReturnClaimToProvider(Edit58)G0378notpayablesameday(APC339)SI=TORE/MorC/CvisitnotpresentsamedayAssignAPC604,SI=V,PI=1,packagingflag=0,linedenialrejectionindicator=0,paymentadjustmentflag=0;discountfactor=1ToG0379AssignAPC0,SI=N;PI=9packagingflag=1,lineitemdenialrejectionflag=0,paymentadjustmentflag=0,discountfactor=1toG0379NoNoNoNoYesYesYesYesYesLineItemRejection(Edit53)IntegratedOCECMSSpecifications–V8.
233AppendixI[OPPSOnly]DrugAdministration(v6.
0–v7.
3only)MaxAPCunitswithmodifier59MaxAPCunitswithoutmodifier59DAAPC422112011171116SumupunitsonDayforAPCXlinesSumofUnitsForAPCX>1ForeachAPCXsubjectedtoYmaximumallowedunitsdothefollowing(eachday);Modifier59PresentonanyAPCXLineYYN1)Assign1UnittofirstlineofAPCX,2)Assignpackagingflag4tootherlinesofAPCX,ifpresent1)AssignuptoYtotalunitspayableofAPCX;totalunitspaid=(min(APCX59units+upto1unitofAPCXnon-59lines),Y)2)Assignpackagingflag4tootherlinesofAPCX,ifpresentNNospecialOCEaction(paytheAPC)IntegratedOCECMSSpecifications–V8.
234AppendixJ[OPPSOnly]Billingforblood/bloodproductsRev39xonthislineRev38xonthesamedayforthiscodeNoEdit–AssignPaymentAdjustmentvaluesofmatchinglinesonthisdayforpayment:5to38xline(s)6to39xline(s)NNYYRev38xonthesamedayforthiscodeandeachwithModBLNSumofUnitsfor39xline(s)forthiscodesameday=SumofUnitsfor38xline(s)forthiscodesamedayNYModifierBLonthislineYNNoEdit;LineisPaidEdit73-Incorrectbillingofbloodandbloodproducts(RTP)Rev38xonthislineNSkip(testedin39xcheck)Rev39xonthesamedayforthiscodeNYYForeachHCPCSontheBloodProductsList,dothefollowing:YIntegratedOCECMSSpecifications–V8.
235AppendixKOCEoverview1.
Ifclaimfrom/throughdatesspanmorethanoneday,subdividethelineitemsontheclaimintoseparatedaysbasedonthecalendardayofthelineitemservicedate.
2.
AssignthedefaultvaluestoeachlineitemintheAPC/ASCreturnbuffer.
ThedefaultvaluesfortheAPCreturnbufferforvariablesnottransferredfrominput,ornotpre-assigned,areasfollows:PaymentAPC/ASC00000HCPCSAPC00000StatusindicatorWPaymentindicator3Discountingformulanumber1Lineitemdenialorrejectionflag0Packagingflag0Paymentadjustmentflag0PaymentmethodflagAssignedinsteps8,20and213.
IfnoHCPCScodeisonalineitemandtherevenuecodeisfromoneoffourspecificlists,thenassignthefollowingvaluestothelineitemintheAPCreturnbuffer.
N-listE-listB-listF-listHCPCSAPC00000000000000000000PaymentAPC:00000000000000000000StatusIndicator:NEBFPaymentIndicator9334Packagingflag:1000IfthereisnoHCPCScodeonaline,andtherevenuecenterisnotonanyofthespecifiedlists,assigndefaultvaluesasfollows:HCPCSAPC00000PaymentAPC:00000StatusIndicator:ZPaymentIndicator3Packagingflag:0IftheHCPCScodeisinvalid,ortherevenuecodeisinvalidandtheHCPCSisblank,assigndefaultvaluesasfollows:HCPCSAPC00000PaymentAPC:00000StatusIndicator:WPaymentIndicator3Packagingflag:0ForclaimswithOPPSflag="1":4.
IfapplicablebasedonAppendixF,assignHCPCSAPCintheAPC/ASCreturnbufferforeachlineitemthatcontainsanapplicableHCPCScode.
IntegratedOCECMSSpecifications–V8.
2365.
Ifprocedurewithstatusindicator"C"andmodifierCAispresentonaclaimandpatientstatus=20,assignpaymentAPC375to"C"procedurelineandsetthediscountingfactorto1.
ChangeSIto"N"andsetthepackagingflagto1forallotherlineitemsoccurringonthesamedayasthelineitemwithstatusindicator"C"andmodifierCA.
Ifmultiplelines,oronelinewithmultipleunits,haveSI=CandmodifierCA,generateedit60foralllineswithSI=CandmodifierCA.
AppendixKOCEOverview(cont'd)6.
Ifedit18ispresentonaclaim,generateedit49forallotherlineitemsoccurringonthesamedayasthelineitemwithedit18,andsetthelineitemdenialorrejectionflagto1foreachofthem.
Gotostep15.
7.
Ifallofthelinesontheclaimareincidental,andallofthelineitemactionflagsarezero,generateedit27.
Gotostep15.
8.
Ifthelineitemactionflagforalineitemhasavalueof2or3thenresetthevaluesofthePaymentAPCandHCPCSAPCto00000,andsetthepaymentmethodflagto4.
Ifthelineitemactionflagforalineitemhasavalueof4,setthepaymentmethodflagto0.
Ignorelineitemswithalineitemactionflagof2,3or4inallsubsequentsteps.
9.
Ifbilltypeis13xandconditioncode=41,ortypeofbill=76x,applypartialhospitalizationlogicfromAppendixC.
Gotostep11.
10.
Ifbilltypeis12x,13xor14xwithoutconditioncode41applymentalhealthlogicfromAppendixC.
11.
Ifbilltypeis13xapplyobservationlogicfromAppendixH.
12.
Ifcodeisonthe"sometimestherapy"list,reassignthestatusindicatortoA,APC0whenthereisatherapyrevenuecodeoratherapymodifierontheline.
13.
IfthepaymentAPCforalineitemhasnotbeenassignedavalueinstep9thru13,setpaymentAPCintheAPCreturnbufferforthelineitemequaltotheHCPCSAPCforthelineitem.
14.
Ifedits9,13,19,20,21,28,39,40,45,47,49,50,53,64,65,67,68,69,76arepresentintheeditreturnbufferforalineitem,thelineitemdenialorrejectionflagforthelineitemissetto1.
15.
ComputethediscountingformulanumberbasedonAppendixDforeachlineitemthathasastatusindicatorof"T",amodifierof52,73or50,orisanontype"T"bilateralprocedure,orisanon-type"T"procedurewithmodifier52or73.
Note:IftheSIorAPCofacodeischangedduringclaimsprocessing,thenewlyassignedSIorAPCisusedincomputingthediscountformula.
Lineitemsthatmeetanyofthefollowingconditionsarenotincludedinthediscountinglogic.
Lineitemactionflagis2,3,or4LineitemrejectiondispositionorlineitemdenialdispositionintheAPC/ASCreturnbufferis1andthelineitemactionflagisnot1Packagingflagisnot0or316.
Ifthepackagingflaghasnotbeenassignedavalueof1or2inpreviousstepsandthestatusindicatoris"N",thensetthepackagingflagforthelineitemto1.
IntegratedOCECMSSpecifications–V8.
23717.
IfthesubmittedchargesforHCPCSsurgicalprocedures(SI=T,orSI=Sincoderange10000-69999)islessthan$1.
01foranylinewithapackagingflagof0,thenresetthepackagingflagforthatlineto3whenthereareothersurgicalproceduresontheclaimwithchargesgreaterthan$1.
00.
18.
ForallbilltypeswhereAPCsareassigned,applydrugadministrationAPCconsolidationlogicfromappendixI.
(v6.
0–v7.
3only)19.
SetthepaymentadjustmentflagforalineitembasedonthecriteriainAppendixGandAppendixJ.
20.
SetthepaymentmethodflagforalineitembasedonthecriteriainAppendixE(a).
Ifanypaymentmethodflagissettoavaluethatisgreaterthanzero,resettheHCPCSandPaymentAPCvaluesforthatlineto'00000'.
21.
Ifthelineitemdenialorrejectionflagis1or2andthepaymentmethodflaghasbeensetto2inthepreviousstep,resetthepaymentmethodflagto3.
ForclaimswithOPPSflag="2":1.
IfapplicablebasedonAppendixF(b),assignPaymentASCpaymentgroup(inthePaymentAPC/ASCfield)intheAPC/ASCreturnbufferforeachlineitemthatcontainsanapplicableHCPCScode.
2.
SetNon-OPPSbilltypeflagasapplicable,basedonthepresenceorabsenceofASCprocedures.
3.
Ifthelineitemactionflagforalineitemhasavalueof2or3thenresetthevaluesofthePaymentASCto00000,andsetthepaymentmethodflagto4.
Ignorelineitemswithalineitemactionflagof2,3or4inallsubsequentsteps.
4.
Ifedits9,28,50,65,67,68,69arepresentintheeditreturnbufferforalineitem,thelineitemdenialorrejectionflagforthelineitemissetto1.
5.
SetthepaymentmethodflagforalineitembasedonthecriteriainAppendixE(b).
6.
Ifthelineitemdenialorrejectionflagis1or2andthepaymentmethodflaghasbeensetto2inthepreviousstep,resetthepaymentmethodflagto3.
IntegratedOCECMSSpecifications–V8.
238AppendixLSummaryofModificationsThemodificationsoftheOCEfortheJuly2007release(V8.
2)aresummarizedintheattachedtable.
Readersshouldalsoreadthroughthespecificationsandnotethehighlightedsections,whichalsoindicatechangefromthepriorreleaseofthesoftware.
SomeOCEmodificationsinthereleasemayalsoberetroactivelyaddedtopriorreleases.
Ifso,theretroactivedatewillappearinthe'EffectiveDate'column.
Mod.
TypeEffectiveDateEdit1Logic7/1/07ModifythesoftwareprogramtoaddtheprocessingofclaimsfromhospitalsthatarenotsubjecttoOPPS(billtypes12x,13x,14x,83xand85x),fordatesofservicebeginning7/1/07(inadditiontoallotherinstitutionaloutpatientproviders).
2Logic7/1/07ActivatetheOPPS/Non-OPPSflagintheOCEcontrolblock.
3Logic7/1/07AssignASCgroupnumberandapplyspecifiededits(appendixF(b))toclaimsfromNon-OPPShospitals(OPPSflag=2).
4Logic7/1/07RenameappendixFto"appendixF(a)"AddappendixF(b)foreditingofclaimsfromNon-OPPShospitalsRenameappendixEto"appendixE(a)"AddappendixE(b)forprocessingofclaimsfromNon-OPPShospitalsModifyappendixKtoaddNon-OPPShospitalclaims5Logic7/1/07Interfacechange–New,1-bytefieldaddedtotheclaimreturnbufferfortheNon-OPPSbilltypeflag.
FlagtobeassignedbytheOCEbasedonthepresence/absenceofASCproceduresonNon-OPPShospitalclaims.
Values:1=Billtypeshouldbe83x2=Billtypeshouldnotbe83x6Content7/1/07MakeHCPCS/APC/SIchangesasspecifiedbyCMS7Content19,20,39,40Implementversion13.
1oftheNCCIfile,removingallcodepairswhichincludeAnesthesia(00100-01999),E&M(92002-92014,99201-99499),orMH(90804-90911).
8ContentAddspecifiedmodifierstothevalidmodifierlist(KG,KK,KL,KT,KU,1P,2P,3P,8P)9Content71Updateprocedure/deviceeditrequirements10Content8/1/0041Removeinvalidcode0620fromthelistofvalidrevenuecodes11Doc7/1/07ChangethenameofthesoftwareprogramfromOutpatientCodeEditorwithAmbulatoryPaymentClassification(OCE/APC)toIntegratedOutpatientCodeEditor(IOCE).
Nochangetoversionnumberingordateranges.
12Doc7/1/07MergetheInstallationandUserManualsfortheOPPSOCEandtheNon-OPPSOCEintoasinglesetofmanualsfortheIntegratedOCE.
1FinalSummaryofDataChangesIntegratedOCEv8.
2EffectiveJuly1,20072TableofContentsCPTcodes,descriptions,andmaterialonlyareCopyright2006AmericanMedicalAssociation.
AllRightsReserved.
Nofeeschedules,basicunits,relativevalues,orrelatedlistingsareincludedinCPT.
TheAMAassumesnoliabilityforthedatacontainedherein.
ApplicableFARS/DFARSrestrictionsapplytogovernmentuse.
DEFINITIONS.
3APCCHANGES.
4AddedAPCs.
4DeletedAPCs.
4APCDescriptionChanges4APCStatusIndicatorChanges…5HCPCS/CPTPROCEDURECODECHANGES.
5AddedHCPCS/CPTProcedureCodes.
5DeletedHCPCS/CPTProcedureCodes.
6HCPCSDescriptionChanges9HCPCSChanges-APC,StatusIndicatorand/orEditAssignments10HcpcsEditChanges10Procedure/DevicePairChanges.
11MODIFIERS.
11AddedModifiers11REVENUECODES.
11DeletedRevenueCodes11ASCASSIGNMENTS.
123DEFINITIONSAblankinafieldindicates'nochange'The"old"columndescribestheattributepriortothechangebeingmadeinthecurrentupdate,whichisindicatedinthe"new"column.
Iftheeffectivedateofthechangeisthesameastheeffectivedateofthenewupdate,'old'describestheattributeuptothelastdayofthepreviousquarter.
Iftheeffectivedateisretroactive,then'old'describestheattributeforthesamedateinthepreviousreleaseofthesoftware.
"Unassigned","Pre-defined"or"Placeholder"inAPCorHCPCSdescriptionsindicatesthattheAPCorHCPCScodeisinactive.
WhentheAPCorHCPCScodeisactivated,itbecomesvalidforuseintheOCE,andanewdescriptionappearsinthe"newdescription"column,withtheappropriateeffectivedate.
ActivationDate(ActivDate)indicatesthemid-quarterdateofFDAapprovalforadrug,orthemid-quarterdateofaneworchangedcoderesultingfromaNationalCoverageDetermination(NCD).
TheActivationDateisthedatethecodebecomesvalidforuseintheOCE.
IftheActivationDateisblank,thentheeffectivedatetakesprecedence.
TerminationDate(TermDate)indicatesthemid-quarterdatewhenacodeorchangebecomesinactive.
AcodeisnotvalidforuseintheOCEafteritsterminationdate.
4APCCHANGESAddedAPCsThefollowingAPC(s)wereaddedtotheIOCE,effective07-01-07APCAPCDescStatusIndicator00943OctagamInjectionK00944GammagardLiquidinjectionK00945RhophylacinjectionK00946HepaGamBIMInjectionK00947FlebogammainjectionK00948GamunexinjectionK00951ReclastinjectionK02638Brachytx,stranded,I-125H02639Brachytx,non-stranded,I-125H02640Brachytx,stranded,P-103H02641Brachytx,non-stranded,P-103H02642Brachytx,stranded,C-131H02643Brachytx,non-stranded,C-131H02698Brachytx,stranded,NOSH02699Brachytx,non-stranded,NOSHDeletedAPCsThefollowingAPC(s)weredeletedfromtheIOCE,effective07-01-07APCAPCDesc01718Brachytxsource,Iodine12501720Brachytxsour,Palladium10302633Brachytxsource,Cesium-13102732Immuneglobulin,liquidAPCDescriptionChangesThefollowingAPC(s)haddescriptionchanges,effective07-01-07APCOldDescriptionNewDescription01716Brachytxsource,Gold198Brachytx,non-str,Gold-19801717Brachytxsource,HDRIr-192Brachytx,non-str,HDRIr-19201719Brachytxsour,Non-HDRIr-192Brachytx,NS,Non-HDRIr-19202616Brachytxsource,Yttrium-90Brachytx,non-str,Yttrium-9002634Brachytxsource,HA,I-125Brachytx,non-str,HA,I-12502635Brachytxsource,HA,P-103Brachytx,non-str,HA,P-10302636Brachytxlinearsource,P-103Brachylinear,non-str,P-10302637Brachytx,Ytterbium-169Brachy,non-str,Ytterbium-1695APCStatusIndicatorChangesThefollowingApc(s)hadStatusIndicatorchanges,effective07-01-07APCOldSINewSI00825KGHCPCS/CPTPROCEDURECODECHANGESAddedHCPCS/CPTProcedureCodesThefollowingnewHCPCS/CPTcode(s)wereaddedtotheIOCE,effective01-01-07HCPCSCodeDescSIAPCEditASCActivDateTermDate3150FForcepsesophbiopsydoneM00000720ThefollowingnewHCPCS/CPTcode(s)wereaddedtotheIOCE,effective07-01-07HCPCSCodeDescSIAPCEditASCActivDateTermDate0178T64LeadECGwI&RB000006200179T64LeadECGwtracingX0010000180T64LeadECGwI&RonlyB000006200181TCornealhysteresisS0023000182THdrelecbrachytherapyS0151903155FCytogentestmarrowb/4txM000007203160FDocfe+storesb/4epothxM000007203170FFlowcytodoneb/4txM000007203200FBariumswallowtestnotreqM000007203210FGrpastreptestperformedM000007204090FPtrcvngepothxpyM000007204095FPtnotrcvngepothxpyM000007204100FBiphosthxpyveinord/rec'vdM000007204110FInt.
mamartusedforcabgM000007204115FBetablckradminw/in24hrsM000007204120FAntibiotrx'd/givenM000007204124FAntibiotnotrx'd/givenM00000720C2638Brachytx,stranded,I-125H02638550C2639Brachytx,non-stranded,I-125H02639550C2640Brachytx,stranded,P-103H02640550C2641Brachytx,non-stranded,P-103H02641550C2642Brachytx,stranded,C-131H02642550C2643Brachytx,non-stranded,C-131H02643550C2698Brachytx,stranded,NOSH02698550C2699Brachytx,non-stranded,NOSH02699550C9728Placedevice/marker,nonprosT00156550G8370AsthmaptwsurveynotdocumM00000720G8371Chemothernotrecstg3colonM00000720G8372Chemotherrecstg3coloncaM00000720G8373ChemoplandocumpriorchemoM00000720G8374ChemoplannotdocpriorcheM000007206HCPCSCodeDescSIAPCEditASCActivDateTermDateG8375CLLptw/odocflowcytometrM00000720G8376BrstcaptineligtamoxifenM00000720G8377MDdoccoloncaptineligchM00000720G8378MDdocptineligradtherapyM00000720G8379Radiattxrecomdoc12moovM00000720G8380PtwstgIC-3Brstcaw/otamM00000720G8381PtwstgIC-3BrstcarectamM00000720G8382MMptw/odocIVbisphophonM00000720G8383Radiationrecnotdoc12moovM00000720G8384MDSptw/obasecytogentestM00000720G8385DiabptwnodocHgbA1c12mM00000720G8386DiabptwnodocLDL12mM00000720G8387ESRDptwHct/HgbnotdocumeM00000720G8388ESRDptwURR/KtvnotdocelM00000720G8389MDSptnodocFepriorEPOM00000720K0553Combinationoral/nasalmaskY00000610K0554ReploralcushioncombomaskY00000610K0555ReplnasalpillowcombmaskY00000610Q4087OctagamInjectionK009430Q4088GammagardLiquidinjectionK009440Q4089RhophylacinjectionK009450Q4090HepaGamBIMInjectionK009460Q4091FlebogammainjectionK009470Q4092GamunexinjectionK009480Q4093Albuterolinhnon-compconB00000620Q4094Albuterolinhnon-compudB00000620Q4095ReclastinjectionK009510S2066BreastGAPflapreconstE0000090S2067Breast"stacked"DIEP/GAPE0000090S3800GenetictestingALSE0000090S3905AutohandhelddiagnervtestE0000090S9152Speechtherapy,re-evalE0000090DeletedHCPCS/CPTProcedureCodesThefollowingHCPCS/CPTcode(s)weredeletedfromtheIOCE,effective04-01-07HCPCSCodeDescJ7319SodiumHyaluronateInjectionThefollowingHCPCS/CPTcode(s)weredeletedfromtheIOCE,effective07-01-07HCPCSCodeDesc0024TTranscathcardiacreduction0133TEsophagealimplantinjexn3101FIntlcarotblk30-99%range3102FIntcarotblk3hG8232PtreceiveddysphagiascreenG8235PtreceivedNPOG8236PtineligdysphagiascreenG8237PtdocrecrehabservG8239Intercarotidstenosis=3hrsb/Ischmstrokesympge3hrsb/43044FHGa1clevel=130-139mmhgSystbpge130-139mmhg3111FCt/mribraindonew/in24hrsCT/MRIbraindonew/in24hrs3112FCt/mribraindone>24hrsCT/MRIbraindoneGT24hrs3120F12-leadecgperformed12-LeadECGperformed3130FUppergiendoscopyperformedUpperGIendoscopyperformed3132FDocref.
uppergiendoscopyDocref.
upperGIendoscopyThefollowingcodedescriptionswerechanged,effective07-01-07HCPCSOldDescriptionNewDescription1100FPtfallsassess-doc'd>=2+/yrPtfallsassess-doc'dge2+/yr1101FPtfallsassessed-doc'd1648noborderAEN/A9J1567Immuneglobulin,liquid0273200000KEN/A28J7611Albuterolnon-compconBE6228J7612Levalbuterolnon-compconBE6228J7613Albuterolnon-compunitBE6228J7614Levalbuterolnon-compunitBE6228J9261NelarabineinjectionKGS2068BreastDIEPorSIEAflap289HcpcsEditChangesThefollowingcode(s)wereaddedtothelistofmaleprocedures,effective01-01-07Hcpcs19300Thefollowingcode(s)wereaddedtothelistoffemaleprocedures,effective01-01-07Hcpcs7705711Procedure/DevicePairChangesThefollowingprocedure/devicecodepairrequirementswereadded,effective10-01-05ProcDevice150688C2625Thefollowingprocedure/devicecodepairrequirementswereadded,effective01-01-07ProcDevice1G0392C1725G0392C1874G0392C1876G0392C1885G0392C2625G0393C1725G0393C1874G0393C1876G0393C1885G0393C2625MODIFIERSAddedModifiersThefollowingmodifier(s)wereaddedtothelistofvalidmodifiers,effective07-01-07modifACTIVATIONDATE1P02P03P08P0KG0KK0KL0KT0KU0REVENUECODESDeletedRevenueCodesThefollowinginvalidrevenuecodewasremovedfromthelistofvalidrevenuecodes,effective08-01-00RevenueCodeSI0620E12ASCASSIGNMENTSThefollowingcode(s)hadanASCassignment,effective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