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MIR-2007-2AB, February 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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January 2007 Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) Specifications Version 8.0
| Note: This article was revised on January 16, 2007, to reflect changes made by CMS to CR5425. The CR release date, transmittal number and Web address for accessing CR5425 were changed. In addition, references to Status Indicators H and K were deleted from the table. All other information remains the same. |
Provider Types Affected
All providers billing outpatient services to Medicare Fiscal Intermediaries (FI), including regional home health intermediaries (RHHI) that are paid under the Outpatient Prospective Payment System (OPPS)
Provider Action Needed
This article is based on information contained in Change Request (CR) 5425 informs FIs that the April 2005 OPPS OCE specifications have been updated with new additions, changes, and deletions, and it instructs FIs to install the updated January 2007 OPPS OCE Specifications (Version 8.0) into their systems.
Background
Full details of Version 8.0 of the OPPS OCE are contained in CR5425 and will not be repeated in this article; especially since many of the details are not changing, and providers paid under the OPPS are likely to be familiar with these details. The modifications of the Outpatient Code Editor/Ambulatory Patient Classification (OCE/APC) for the January 2007 release (V8.0) are summarized in the following table:
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Mod. Type |
Effective Date |
Edit |
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1. |
Logic |
1/1/07 |
|
Add new payment adjustment flag (PAF) 7; assign to procedures subject to offset, when modifier FB is present. Reduce APC payment rate by offset amount before application of discounting logic |
2. |
Logic |
1/1/07 |
75 |
New edit 75 – Incorrect billing of modifier FB (RTP)
- If modifier FB is present and SI is not S, T, V or X |
3. |
Logic |
1/1/07 |
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Special packaged codes with SI = Q
- Change SI and assign APC if no other code subject to APC payment is present on the same day
- Change SI to N if another code that is subject to APC payment is present on the same day
- Pay the highest APC if more than one special packaged code qualify for payment on the same day |
4. |
Logic |
1/1/07 |
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Add G0104, G0105, G0106, G0120, G0121, and G0389 to the “Deductible Not Applicable” list. |
5. |
Logic |
1/1/07 |
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Deactivate special drug administration logic (Appendix I)
Deactivate packaging flag 4 (Packaged as part of drug administration APC payment) |
6. |
Logic |
1/1/07 |
71 |
Expand edit 71 to trigger if some specified devices are present on a claim without the required procedure (reverse device edit). |
7. |
Logic |
1/1/07 |
76 |
New edit 76 – Trauma response critical care code without revenue code 068X and CPT 99291 (LIR)
- If the trauma response critical care code is present without revenue code 068X and CPT code 99291 on the same date of service (DOS). |
8. |
Logic |
1/1/07 |
15 |
Assign unit of service = 1 for code G0390 |
9. |
Logic |
7/1/02 |
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Remove bill type 74X from the box in Appendix E that assigns only Payment Method Flags 1 & 2 |
10. |
Logic |
1/1/07 |
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Update medical visit APC numbers in Appendix H. |
11. |
Content |
|
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Make HCPCS/APC/SI changes, as specified by CMS. |
12. |
Content |
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19,20, 39,40 |
Implement version 12.3 of the NCCI file, removing all code pairs which include Anesthesia (00100-01999), E&M (92002-92014, 99201-99499), or MH (90804-90911); and the following Drug Admin code pairs: C8950-C8952, C8953-C8950, C8953-C8952, C8954-C8950, C8954-C8952, C8954-C8953.
Change modifier indicator from 0 to 1, effective 4/1/06, for the following code pairs:
G0245 – 97597
G0245 – 97598
G0246 – 97597
G0246 – 97598
G0247 – 97597
G0247 – 97598
67221 – C8950
67221 – 90760
67221 – 90765
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13. |
Content |
1/1/06 |
22 |
Correct the effective date of new CPT modifiers (genetic testing category) added to global “valid modifier” list. |
14. |
Content |
|
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Add and delete modifiers as specified by CMS and/or as found on the HCPCS master tape. |
15. |
Doc |
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71 |
Modify description for edit 71: Claim lacks required device or procedure code |
16. |
Doc |
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10 |
Modify description for edit 10: Service submitted for denial (condition code 21) |
17. |
Doc |
|
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UB-04 form locators for claim input values added to tables #1 and #2 |
18. |
Doc |
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Appendix C – Revise text of PH payment APC assignment footnote to clarify that AT, OT, and ET are not assigned to HCPCS APCs. |
You should also read through the specifications in the official instruction (CR 5425) issued to your intermediary, and note the highlighted sections, which also indicate changes from the prior release of the software. Some OCE/ APC modifications in the release may also be retroactively added to prior releases. If so, the retroactive date appears in the “Effective Date” column in the above table.
Additional Information
For complete details, please see the official instruction issued to your FI/RHHI regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1155CP.pdf  on the CMS Web site.
If you have any questions, please contact your FI/RHHI at their toll-free number, which may be found on the CMS Web site at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  .
Flu Shot Reminder
As a respected source of health care information, patients trust their doctors’ recommendations. If you have Medicare patients who haven’t yet received their flu shot, help protect them by recommending an annual influenza and a one time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. - And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article 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.
MLN Matters Number: MM5425
Pub. 100-4, Transmittal# R1155CP, CR# 5425
Related CR Release Date: January 12, 2006
Effective Date: January 1, 2007
Implementation Date: January 2, 2007
Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/  on the CMS Web site.
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