The Integrated Outpatient Code Editor I/OCE V15.0

The Integrated Outpatient Code Editor I/OCE V15.0 April 2014 Updated 1 Disclaimer Duke University Medical Center Durham, NC The comments expressed throughout this presentation are our opinions, predicated on our interpretation of CMS regulations/guidelines and our professional healthcare experiences. CPT codes and descriptions only are copyright 2014 American Medical Association. All rights reserved. 2 1

Presentation Outline Claim Life Cycle Claim form UB-04 (CMS 1450) and NUBC Data Elements Charge Description Master (CDM) CMS Editing Claim Flow I/OCE Edits and Special Processing Rules History and Versions of I/OCE I/OCE Disposition Concepts Appendices APCs Inactive Edits and Special Processing Rules Active Edits and Special Processing Rules Questions University of North Carolina at Chapel Hill Morehead Patterson Bell Tower 3 OPPS/non-OPPS This presentation pertains to claims subject to the Outpatient Prospective Payment System (OPPS). Most facilities are subject to OPPS with the exception of Critical Access Hospitals (CAHs), Community Mental Health Centers (CMHCs), Indian Health Service hospitals; hospitals located in American Samoa, Guam, Saipan and the Virgin Islands and certain hospitals in Maryland which are paid under the Maryland waiver provisions. Wake Forest University Baptist Medical Center Winston Salem, NC 4 2

Claim Form CMS 1450 (Uniform Bill or UB-04) Electronic claims submission is in the 837I (institutional) format. Companion Guide describes some data elements https://www.cms.gov/medicare/billing /ElectronicBillingEDITrans/download s/5010a2837acg.pdf See also: technical documentation information http://www.cms.gov/medicare/billing/ MFFS5010D0/Technical- Documentation.html 5 National Uniform Billing Committee Excerpt from Medicare publication UB-04 Overview Background The National Uniform Billing Committee (NUBC) is responsible for the design and printing of the UB-04 form. The NUBC is a voluntary, multidisciplinary committee that develops data elements for claims and claim-related transactions, and is composed of all major national provider and payer organizations (including Medicare). The 837 Institutional electronic claim format is the electronic version of the form and is in use by providers who submit claims electronically. Visit Chapter 25 of the Medicare Claims Processing Manual, Internet-Only Manual Publication (IOM Pub) 100-04 at http://www.cms.gov/manuals/downloads/clm104c25.pdf to learn more about the UB-04. Additional information is available to subscribers of the Official UB-04 Data Specifications Manual. Visit the NUBC website at http://www.nubc.org to subscribe. This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. This publication contains information regarding required fields, the size and type of data each field can hold. See CMS Manual 100-04, Chapter 25 for more information. 6 3

Data Elements Each claim will consist of some or all of the following data elements for processing in I/OCE. Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. 7 Charge Description Master (CDM) The CDM is a large electronic file which contains the charge books for each of the facility departments. The CDM contains coding information (CPT, HCPCS and National Drug Codes), quantity (quantity in a single unit for the charge code for example, 10ml), modifiers (some modifiers can be hard-coded in the CDM for example, GP for services delivered under an outpatient physical therapy plan of care may be hard-coded for some services for certain PT services) and the charges associated with that service or procedure. Physician coders choose the charge code (which may be a CPT code) which maps to pricing information in the CDM based on documentation. The coding on outpatient facility claims are often obtained when technicians, nurses or other personnel enter the charge code at the time of service. 8 4

CMS Editing Medicare (CMS) has many processes for claims editing. Common Edit Module (CEM) Edits claims from facilities and professionals in the electronic files (837 institutional and 837 professional) for items such as code sets (appropriate use and validity of codes such as country codes, zip codes, ambulance modifiers, drug codes (NDC), condition codes, value codes, occurrence codes, HIPPS codes), it also checks for duplicates and assigns the document control number (DCN). Medicare Code Editor (MCE) Edits inpatient facility claims by performing 3 types of Edits and Processing Rules prior to assigning a DRG: correct use of ICD-9 diagnosis and procedure codes (validity and relationships), coverage (are services covered for the patient type inpatient etc), and clinical consistency (for DRGs) Fiscal Intermediary Shared or Standard System (FISS) this is the system which handles claims submitted by facilities. With certain exceptions, FIs perform bill processing and benefit payment functions for Part A of the program (Hospital Insurance) and carriers perform claims processing and benefit payment functions for Part B of the program (Supplementary Medical Insurance). Medicare carriers determine payment amounts and make payments for services (including items) furnished by physicians and other suppliers such as nonphysician practitioners (NPP), laboratories, and durable medical equipment (DME) suppliers. Integrated Outpatient Code Editor (I/OCE) - The Integrated' Outpatient Code Editor (I/OCE) program processes claims for all outpatient institutional providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as hospitals that are NOT (Non-OPPS). It is the subject of this presentation. Common Working File (CWF) - The Common Working File is a Medicare tool which handles benefit coordination and claims validation. It is used to verify entitlement, maintain utilization data (such as, yearly visit allowances etc.) and prevent improper payment (comparison of Part A and Part B claims). 9 Puzzled on the CMS Claim Flow? Common Working File (CWF) Entitlement and utilization review. Authorization. Some claim scrubbing. CWF CWF Provider FISS Fiscal Intermediary Shared System (FISS) and OCE. Claim is edited but not paid. Pricing, payment, rejection, etc. FISS Provider CMS Provider 10 5

Integrated Outpatient Code Editor (I/OCE) Three functions: 1. Edit data and return edit flags 2. Assign Ambulatory Payment Classifications (APCs) 3. Assign Ambulatory Surgical Center (ASC) groups for non-opps(out Patient Prospective Payment System) hospitals Claims contain multiple dates of service but, it is the user s responsibility to gather all services on a single record Claims processing is on a single claim only (no history) Accepts up to 450 lines per claim Single claim line may receive multiple Edits and Processing Rules The OCE not only identifies individual errors but also indicates what actions should be taken and the reasons why these actions are necessary. In order to accommodate this functionality, the OCE is structured to return lists of edit numbers. This structure facilitates the linkage between the actions being taken, the reasons for the actions and the information on the claim (e.g., a specific diagnosis) that caused the action). 11 I/OCE Overview I/OCE is updated quarterly There are currently 87 numbered Edits and 22 Processing Rules in the most recent CMS I/OCE specification V15.0 = January, 2014. 20 are not currently active (were active in previous versions, were never activated or were deleted and combined with other Edits) 1 edit (#15 Service unit out of range for procedure) Currently active, however there is no data associated with it. 67 current active Edits 1 special processing rule, Rule 5, is no long in effect (multiple drug APCs on same date require modifier 59) 12 6

History and Versions of I/OCE The Outpatient Code Editor (OCE) was developed for the implementation of the Medicare OPPS mandated by the 1997 Balanced Budget Act. CMS proposed the OPPS rules using the APC system in September 1998. Final regulations were published April 7, 2000. The OCE system became effective on August 1, 2000 for dates of service on or after July 1, 2000. The I/OCE is updated quarterly. A version identification number is assigned to the CMS Specifications Version for each quarter. The CMS I/OCE maintains 28 prior quarters (7 years) of programs in each release. Valid versions: 27 = April 2007 = 8.1 28 = July 2007 = 8.2 29 = October 2007 = 8.3 30 = January 2008 = 9.0 31 = April 2008 = 9.1 32 = July 2008 = 9.2 33 = October 2008 = 9.3 34 = January 2009 = 10.0 35 = April 2009 = 10.1 36 = July 2009 = 10.2 37 = October 2009 = 10.3 38 = January 2010 = 11.0 39 = April 2010 = 11.1 40 = July 2010 = 11.2 41 = October 2010 = 11.3 42 = January 2011 = 12.0 43 = April 2011 = 12.1 44 = July 2011 = 12.2 45 = October 2011 = 12.3 46 = January 2012 = 13.0 47 = April 2012 = 13.1 48 = July 2012 = 13.2 49 = October 2012 = 13.3 50 = January 2013 = 14.0 51 = April 2013 = 14.1 52 = July 2013 = 14.2 53 = October 2013 = 14.3 54 = January 2014 = 15.0 13 14 7

Edit Disposition Concepts Return to Provider, Reject, Deny, Suspend Claim Rejection occurs when an edit causes the entire claim to reject. The provider may make necessary corrections and resubmit the claim. This is usually related coverage of the services submitted; for example, only incidental services are submitted (edit 27).(The claim is accepted so the resubmission needs to have a corrected claim bill type xx7). Claim Denial occurs when an edit causes the entire claim to deny. The provider may appeal the denial but cannot resubmit the claim. Example, edit 10, submitted for denial. This would be the case when it is necessary to have the denial from Medicare prior to processing the claim by the secondary payer. Return to provider (RTP) occurs when an edit fires which prevents proper processing of the claim. The provider can correct the data element which is responsible for the edit and resubmit the claim. (These claims have not been accepted and should be resubmitted as new claims, bill type = xx1). Claim Suspension occurs when the FI/MAC needs to manually review the claim prior to payment. For example, edit 66 (code requires manual pricing). Line item rejection is similar to claim rejection except that the rest of the claim continues to process. Line item denial is similar to claim denial except that the rest of the claim continues to process. 15 I/OCE Specification Appendices Appendix A - Bilateral Procedure Logic (OPPS & Non-OPPS) Appendix B - Rules for Medical and Procedure Visits on the Same Day and for Multiple Medical Visits on the Same Day (OPPS Only) Appendix C(a) PHP and Mental Health Logic (OPPS Only) Appendix D - Computation of Discounting Fraction (OPPS Only) Appendix E(a) - Logic for Assigning Payment Method Flag Values to Status Indicators by Bill Type Appendix F(a) OCE Edits Applied by Bill Type Appendix F(b) OCE Edits Applied by Non-OPPS Bill Type Appendix G Payment Adjustment Flag Values (OPPS Only) Appendix H (OPPS Only) Appendix I Drug Administration (OPPS Only) Appendix J Billing for blood/blood products (OPPS Only) Appendix K Composite APC Assignment Logic Appendix L OCE overview Appendix M Summary of Modification Appendix N Code Lists Referenced within CMS I/OCE Spec Document 16 8

Row # Provider/Bill Types Edits Applied (by edit number) 1 12x or 14x with condition code 41 46 2 12x or 14x without condition code 41 1-9, 11-18, 20-23, 25-28, 35-38, 40-45, 47-50, 52-54, 56-58, 60-79, 81-85, 87 3 13x with condition code 41 1-9, 11-18, 20-23, 25-28, 29-34, 37, 38, 40-45, 47-50, 52, 54, 56-58, 60-62, 65-80, 82 85, 87. 4 13x without condition code 41 1-9, 11-18, 20-23, 25-28, 35-38, 40-45, 47-50, 52, 54, 56-58, 60-79, 81, 82-85, 87 5 76x (CMHC) 1-9, 11-13, 15, 18, 23, 25, 26, 29-34, 38, 41, 43-45, 47-50, 53-55, 61, 65, 69, 71-73, 75, 77-80, 82, 84, 85, 87 6 34x (HHA) with Vaccine, Antigens, Splints or Casts 1-9, 11-13, 15, 18, 20, 25-26, 28, 38, 40, 41, 43-45, 47, 49-50, 53-55, 62, 65, 69, 71, 73, 75, 77-79, 82, 84, 85, 87 7 34x (HHA) without Vaccine, Antigens, Splints or Casts 1-9, 11-13, 20, 25, 26, 40-41, 44, 50, 53-55, 65, 69. 8 75x (CORF) with Vaccine (PPS) [v1-6.3] 1-9, 11-13, 15, 18, 20, 25, 26, 38, 40-41, 43-45, 47-50, 53-55, 61, 62, 65, 69, 71-73, 75, 77-79, 82, 84, 85, 87 9 43x (RNHCI) 25, 26, 41, 44, 46, 55, 65. 10 71x (RHC), 73x/77x (FQHC) 1-5, 25, 26, 41, 61, 65, 72. 11 Any bill type except 12x, 13x, 14x, 34x, 43x, 71x, 73x/77x, 76x, with CC 07, with Antigen, Splint or Cast 1-9, 11-13, 18, 23, 25, 26, 28, 38, 41, 43-45, 47, 49, 50, 53-55, 62, 65, 69, 71, 73, 75, 77-79, 82, 84, 85, 87. 12 75x (CORF) 1-9, 11-13, 15, 20, 23, 25, 26, 40, 41, 44, 48, 50, 53-55, 61, 65, 69, 72. 13 22X, 23X (SNF), 24X 1-9, 11-13, 20, 23, 25, 26, 28, 40-41, 44, 50, 53, 54, 55, 61, 62, 65, 69, 72. 14 32X, 33X (HHA) 1-5, 7-9, 11, 12, 25, 26, 41, 44, 50, 53-55, 65, 69. 15 72X (ESRD) 1-5, 7-9, 11, 12, 25, 26, 41, 44, 50, 53, 54, 55, 61, 65, 69, 72. 16 74X (OPT) 1-9, 11-13, 20, 25, 26, 40-41, 44, 48, 50, 53, 54, 55, 61, 65, 69, 72. 17 81X (Hospice), 82X 1-5, 7-9, 11, 12, 25, 26, 41, 44, 50, 53, 54, 55, 61, 65, 69, 72, 86. Appendix F(a) OCE Edits Applied by Bill Type [OPPS flag =1] 17 Note # FLOW CHART ROWS ARE IN HIERARCHICAL ORDER. 1 Edit 10, and edits 23 and 24 for From/Through dates, are not dependent on Appendix F. 2 If edit 23 is not applied, the lowest service (or From) date is substituted for invalid dates and processing continues. 3 Edit 22 is bypassed if revenue code is 540. 4 Edit 77 is not applicable to bill type 12x (rows #1 and #2). 5 Bypass edit 48 if revenue code is 100x, 210x, 310x, 0500, 0509, 0521, 0522, 0524, 0525, 0527, 0528, 0583, 0637, 0660-0663, 0669, 0905-0907, 0931, 0932, 0948, 099x. 6 In V1.0 to V3.2, vaccines included all vaccines paid by APC; from V4.0 forward, vaccines includes Hepatitis B vaccines only, plus Flu, H1N1 and PPV administration. 7 Bypass diagnosis edits (1-5) for bill types 32x and 33x (HHA) &12x (inpt/b) if From date is before October 1 and Through date is on or after October 1. And for bill types 322 & 332 if From date is between 9/26 and 9/30, inclusive. Note: Bill type 33X is deleted as of 10/1/2013. 8 Bill type 24x deleted, effective 10/1/05. 9 NCCI edits (20, and 40) applied to bill types 22x, 23x, 34x, 74x and 75x effective 1/1/06. 10 Edit 28 applied to bill type 22x and 23x effective 10/1/05. 11 Effective 4/1/06, MH edits (35, 36, 63, 64 and 81) not applicable to TOB 14x. 12 If TOB is 81x or 82x and RC = 657, bypass edit 72 for any HCPCS code with SI =M (& change the SI from M to A). 13 Change TOB for FQHC from 73x to 77x, effective 4/1/10. 14 Psychiatric add-on codes trigger edit 84 only on PHP claims (TOB 13x w/cc41 & 76x). 15 Edit 86 applied to bill types 81X and 82X only, effective 10/01/2013. 18 9

About APC s Each HCPCS code that represents a service paid under OPPS is assigned to an APC. Other services are identified by a status indicator (SI) representing the method of payment. APCs are applied in the full range of ambulatory settings, including same day surgery, hospital ER, and outpatient clinics. A list of HCPCS/CPT code along with the APC, and status indicator can be found in Addendum B of the Hospital Outpatient PPS. Types of APCs are: Significant procedure - In general, surgical APCs are specified by SI=T; for non-surgical significant procedures SI = S. Drug/Biological pass-through - SI = G Device pass-through - SI = H Brachytherapy sources - SI = U Medical visit - SI = V Ancillary service - SI = X Non-pass-through drug or non-implantable biologicals, including therapeutic radiopharmaceuticals SI = K Blood and blood products - SI = R Partial hospitalization - SI = P 19 Inactive Edits and Processing Rules Edit # Description Active Versions 4 Medicare secondary Payer Alert 1.0-1.1 7 Procedure and age conflict not activated 13 Separate payment for service is not paid by Medicare 1.0-6.3 14 Code indicates a site of service not included in OPPS 1.0-6.3 16 Multiple bilateral procedures without modifier 50 1.0-6.2 19 Mutually exclusive procedure that is not allowed by NCCI even if appropriate modifier is present deleted retroactively in v13.2 31 Partial hospitalization on same day as ECT or type T procedure 1.0-6.3 32 Partial hospitalization claim spans 3 or less days with insufficient services on at least one of the days. 1.0-9.3 33 Partial hospitalization claim spans more than 3 days with insufficient number of days having partial hospitalization services 1.0-9.3 34 Partial hospitalization claim spans more than 3 days with insufficient number of days meeting partial hospitalization criteria 1.0-9.3 36 Extensive mental health services provided on day of ECT or type T procedure 1.0-6.3 39 Mutually exclusive procedure that would be allowed by NCCI if appropriate modifier were present deleted retroactively in v13.2 51 Multiple observations overlap in time not activated 52 Observation does not meet minimum hours, qualifying diagnoses, and/or "T" procedure conditions 3.0-6.3 56 E/M condition not met and line item date for OBS code G0244 is not 12/31 or 1/1 4.0-6.3 59 Clinical trial requires diagnosis code V70.7 as other than primary diagnosis deleted retroactively in v11.2 63 This OT code only billed on partial hospitalization claims 1.0-13.3 64 AT service not payable outside the partial hospitalization program 1.0-13.3 Special processing rule #5 When multiple occurrences of any APC that represents drug administration are assigned in a single day, modifier -59 is required on the code(s) in order to permit payment for multiple units of that APC, up to a specified maximum; additional units above the maximum are packaged. If modifier -59 is not used, only one occurrence of any drug administration APC is allowed and any additional units are packaged. v6.0-v7.3 only 20 10

Active Edits and Processing Rules University of North Carolina Health Care System Chapel Hill, NC 21 Data Validity Edits Edit # Description 1 Invalid Diagnosis Code 6 Invalid Procedure Code 22 Invalid Modifier 23 Invalid date 24 Date out of OCE range 25 Invalid age 26 Invalid sex 41 Invalid revenue code 65 Revenue code not recognized by Medicare 22 11

Diagnosis Related Edits Edit # Description 2 Diagnosis and age conflict 3 Diagnosis and sex conflict 5 E-diagnosis code cannot be used as principle diagnosis 56 Manifestation code not allowed as principle diagnosis 23 Procedure/Revenue/Modifier Code Edits and Processing Rules Edit # Description 8 Procedure and sex conflict 54 Multiple codes for the same service 76 Trauma response critical care code without revenue code 68x and CPT 99291 - HCPCS code G0390 48 Revenue code requires HCPCS 42 Multiple medical visits on same day with same revenue code without condition code G0 79 Incorrect billing of revenue code with HCPCS code 17 Inappropriate specification of bilateral procedure 37 Terminated bilateral procedure or terminated procedure with units greater than one 74 Units greater than one for bilateral procedure billed with modifier 50 21 Medical visit on same date a type T or S procedure without modifier 25 24 12

Procedure/Revenue/Modifier and Code Edits and Processing Rules, Continued Special processing rules 12) S, T, V or X Packaging Rules STVX packaging HCPCS codes with status indicator (SI) = Q1 are packaged when another HCPCS with SI=S, T, V or X is present on the same date. Example: 36591(Q1) with 29580(S) T packaging - HCPCS codes with status indicator (SI) = Q2 are packaged when another HCPCS with SI=T is present on the same date. Example: 65778(Q2) with 65091(T) If not other lines with HCPCS with the specified SI are present, the code with SI=Q1 or Q2 will be paid separately. 13) Trauma Response Rules Trauma response critical care code (G0390) requires trauma revenue code (68x) and critical care E&M (99291) on the same date of service; otherwise, trauma response critical care code is rejected. Note: this processing rule is fully encompassed in Edit #76. 18) Ancillary Critical Care Packaging Rules Certain ancillary services are conditionally packaged into critical care services when furnished on the same date. The list of the packaged services is not available on the CMS website. However, it is a subset of the codes listed in the physician rules found in CPT(the codes which are not SI= N,A or B). This rule can be bypassed when modifier 59 is present on the ancillary service. These packaged services have SI=Q3 but not all Q3 codes are packaged into critical care. 25 National Correct Coding Initiative (NCCI) Edits NCCI rules were established to check for code pairs that shouldn t be billed together on the same date for the same patient. All applicable NCCI edits are incorporated into the I/OCE. Both codes in a NCCI code pair may be allowed if an appropriate modifier is used that describes the circumstances when both service may be allowed. These codes will have a modifier indicator of 1 whereas codes pairs that are never allowed, with or without an approved modifier present are identified with a modifier indicator of 0 #20 Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is present. (Modifier indicator = 0. Example: 59620 and 59050 #40 Code2 of a code pair that would be allowed by NCCI if an appropriate modifier were present. (Modifier indicator = 1. Example: 20610 and 10140 Modifiers that are recognized/used to describe allowable services are : 25, 27, 58, 59, 78, 79, 91, E1-E4, F1-F9, FA, LC, LD, LT, RC, T1-T9, AND TA 26 13

Inpatient Only Edits and Processing Rules Edit # Description 18 Inpatient procedure. An inpatient only procedure is identified by SI=C 45 Inpatient separate procedure not paid 49 Service on same day as inpatient procedure 60 Use of CA modifier with more than one procedure not allowed 70 CA modifier requires patient status code 20 Special processing rules #3) One inpatient only procedure is allowed when the patient expires prior to admission. The patient status code on the claim will be 20 (expired) and modifier CA should be appended to the inpatient procedure. A single APC is paid for that date. #4) The inpatient only edit (18) is bypassed when an inpatient only separate procedure is performed with a SI=T (significant procedure subject to reduction). Edit 45 will fire, the line will be rejected but the claim will continue processing. 27 Partial Hospitalization/ Mental Health Edits Edit # Description 29 Partial hospitalization service for non-mental health diagnosis 30 Insufficient services on day of partial hospitalization 35 Only Mental Health educational and training services provided 46 Partial hospitalization condition code 41 not approved for type of bill 80 Mental health code not approved for partial hospitalization program 81 Mental health service not payable outside the partial hospitalization program 28 14

Partial Hospitalization/Observation/Mental Health Processing Rules Special processing rules 1) Per diem partial hospitalization level I or level II are paid when the condition code, bill type and HCPCS fall within the partial hospitalization guidelines. (Condition code 41 = partial hospitalization Bill type = 13x(Hospital Outpatient) or 76x(Community Mental Health Center). HCPCS = codes identified in Appendix N of the I/OCE specifications, list A and B. Also see appendix C-a. All partial hospitalization services are packaged on the day. If multiple days on the claim represent partial hospitalization services, multiple APCs are paid. If less than the minimum allowed services(for partial hospitalization) are provided the partial hospitalization is denied. Mental health services which are not approved for partial hospitalization are not allowed on the partial hospitalization claim (the claim will RTP). 2) 2) Mental health services provided outside of the partial hospitalization are allowed up to the Cap which is equal to the level II partial hospitalization. If services exceed the cap, a composite APC is assigned to one service and the others are packaged (changed to status indicator = N). Note, claims with codes that are not approved outside of partial hospitalization will be returned to the provider when submitted without condition code 41 indicating partial hospitalization. This rule establishes a maximum payment rate (Cap) for mental health services regardless of partial hospitalization status. The Cap is equal to the payment rate for the level II mental health partial hospitalization rate (APC=176 for bill type 13x-Hospital Outpatient and APC 173 for bill type 76x-Community Mental Health Center.) 29 There are special provisions for paying for observation under OPPS. CMS has developed lists for covered services and the requirements which must be met for services to be covered. There are also lists of services which are not covered for partial hospitalization. Please see Appendix K in the I/OCE specifications and the Claims Processing Manual 100-04, Chapter 4 (Part B Hospital including Inpatient Part B and OPPS) Section 290 Outpatient Partial Hospitalizations Services for complete details. #44 Observation revenue code on line item with non-observation HCPCS code. #53 Codes G0378 and G0379 only allowed with bill type 13x or 85x #57 Composite E/M condition not met for observation and line item date for code G0378 is 1/1 #58 G0379 only allowed with G0378 Special processing rules 7) Observation is always packaged, not paid separately. It may be paid under the extended assessment and management composites and is only covered for bill types 13x(Hospital Outpatient) and 85x(Critical Access Hospital). For Medicare, observation is reported with HCPCS code G0378. There are two levels of extended assessment and management. Level I, APC 8002, requires a level 5 E&M (new or established patient) or a direct referral for observation) on the same day or day before admission for observation. Level II, APC 8003, requires a level 4 or 5 Emergency Room E&M, Critical Care or Level 5 Emergency Room in type B emergency department on the same day or day before admission for observation. Also see Appendix K. 8) Direct referral for observation may be packaged into other services: extended assessment and management, Status T, V or critical care or may be processed as a medical visit. 30 15

Coverage Edits and Processing Rules Edit # Description 9 Non-covered under any Medicare outpatient benefit, for reasons other than statutory exclusion 10 Service submitted for denial (condition code 21) 11 Service submitted for FI/MAC review (condition code 20) 12 Questionable covered service 27 Only incidental services reported 28 Code not recognized by Medicare for outpatient claims; alternate code for same service may be available 31 Coverage Edits and Processing Rules Continued Edit # Description 47 Service is not separately payable 50 Non-covered under any Medicare outpatient benefit, based on statutory exclusion 55 Not reportable for site of service 61 Service can only be billed to the DMERC 62 Code not recognized by OPPS; alternate code for same service may be available 66 Code requires manual pricing 72 Service not billable to the FI/MAC 32 16

Coverage Edits and Processing Rules Continued Special processing rules 10) Wound Care Services may be paid under the Physician Fee Schedule or paid an APC depending on the circumstances. Wound care services fall into the sometimes therapy services. When submitted with therapy modifiers (GO, GN or GP) or when reported with therapy revenue codes (42x, 43x or 44x) these services are paid under the Medicare Physician Fee Schedule. Otherwise, these services are paid by APC under OPPS. 22) Skin substitutes are packaged when they are not submitted with skin substitute application procedures. They are paid separately with the standard APC when provided in conjunction with a skin substitute grafting procedure. 16) Medicare managed care beneficiaries are not subject to line level deductibles. 19) Deductibles and co-insurance is waived for some preventive services. Deductibles are waived for any code in the surgical CPT range (10000-69999) when modifier PT is present on another code in the surgical range on the same day. 17) For bill types 81x and 82x (hospice) codes with status indicator M will be changed to status indicator A when the revenue code is 657. 33 Approval Edits Edit # Description 67 Service provided prior to FDA approval 68 Service provided prior to date of National Coverage Determination (NCD) approval 69 Service provided outside approval period 83 Service provided on or after effective date of NCD non-coverage 34 17

Relationship Edits and Processing Rules Edit # Description 38 Inconsistency between implanted device or administered substance and implantation or associated procedure 71 Claim lacks required device code. 73 Incorrect billing of blood and blood products 77 Claim lacks allowed procedure code 78 Claim lacks required radiolabeled product 35 Relationship Edits and Processing Rules Continued Edit # Description 75 Incorrect billing of modifier FB or FC 82 Charge exceeds token charge ($1.01) 84 Claim lacks required primary code 85 Claim lacks required device code or required procedure code 36 18

Relationship Edits and Processing Rules Continued Special processing rules 6) A device (or devices) are required for the performance of some procedures. When the procedure is submitted without a device, the claim is RTP (edit 71, for example). However, sometimes the procedure may be discontinued prior to insertion of the device (modifier 52, 73 or 74). When one of these modifiers is present on the procedure line, the claim will not be RTP for the device. 9) Please see Appendix J of the I/OCE specification for more details about this rule. In general, blood processing and storage requires two lines; one with a 39x (blood administration, processing and storage) and one with 38x (blood and blood components). There are many nuances to billing for blood and blood administration. The American Red Cross has a lot of good information on this subject. http://www.redcrossblood.org/hospitals/educational-resources/reimbursement 11) When an implantable device is provided at no charge to the provider, modifier FB must be appended. When a device is provided at a discount, modifier FC must be appended. When one of these circumstances occur, the APC will be reduced. If both FB and FC modifiers are submitted the service will be processed as if only modifier FB were present. This is a general overview of this special rule. Please see the I/OCE specifications for more details. 15) Medicare requires a radiolabeled product when a nuclear medicine procedure is performed. If the radiolabeled product is not on the claim, it will RTP. Sometimes a patient may have a nuclear medicine procedure along with a radiopharmaceutical one day and may return for another nuclear medicine procedure later in the week. Medicare provides directions for how to handle these situations. Please see the Claims Processing Manual 100-04, Chapter 4, Section 200.8 for more details. http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c04.pdf 37 Relationship Edits and Processing Rules Continued Special processing rules 20) Special processing rule 20 (edit 84) concerns add-on codes. Claims with add-on code 33225 will be returned to the provider if not submitted with a primary code. In addition, psychiatric add-on codes 90785, 90833, 90836 or 90838 will be returned to the provider when submitted on a partial hospitalization claim (condition code 41) without a primary code. 21) When a prosthesis is present without a telescopic lens (or vice versa) the claim will be RTP unless the procedure was discontinued (modifier 52, 73 or 74). 38 19

Final Composite Packaging What is a composite? A composite is a grouping of services which are bundled or packaged into a single item for payment purposes. Many procedures/services which are packaged into composites have SI= Q3. The primary code for the group is assigned the composite APC and the other services which make up the composite are assigned SI=N. Terminated procedures (modifier 52 or 73) are not included in composites. When the composite criteria is not met, the standard APC would apply. Composites are located in the I/OCE Specification in Appendix K. Composites include: LDR (low dose radiation) prostate brachytherapy Electrophysiology/ablation Extended Assessment and Management Separate Direct Referral Critical Care Cardioverter Defibrillator and Pacing Electrode Multiple Imaging Composites Ultrasound CT/CTA with and without contrast MRI and MRA with and without contrast 39 Questions? 40 20