Provider Types Affected
Non-OPPS hospitals submitting outpatient claims to Medicare Fiscal Intermediaries (FI) for services provided to Medicare beneficiaries

Provider Action Needed
This article is based on Change Request (CR) 5344 which informs FIs of the integration and testing of the non-Outpatient Prospective Payment System (non-OPPS) OCE into the OPPS OCE effective July 1, 2007.

Background
This article is based on Change Request (CR) 5344 which informs your Fiscal Intermediary (FI) of the integration and testing of the non-Outpatient Prospective Payment System (non-OPPS) OCE into the OPPS OCE effective July 1, 2007.

The integration of the non-OPPS OCE into the OPPS OCE:

• Will result in the routing of all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE eliminating the need to update, install, and maintain two separate OCE software packages on a quarterly basis.
• Does not change the current logic that is applied to outpatient bill types that already pass through the OPPS OCE software. It merely expands the software usage to include non-OPPS hospitals. Note: This new software product will be referred to as the Integrated OCE .

Note: Claims with dates of service prior to July 1, 2007 will be routed through the non-integrated versions of the OCE software (OPPS and non-OPPS OCEs) that coincide with the versions in effect for the date of service on the claim.

The principal reason for the integration of the non-OPPS OCE into the OPPS OCE is the long-standing systems issues related to the non-OPPS OCE software that require corrective action.

Editing that only applied to OPPS hospitals (e.g., blood, drug, partial hospitalization logic) in the past will not be applied to non-OPPS hospitals at this time. However, with the integrated OCE, non-OPPS hospitals will be assigned specific edit numbers and dispositions, where in the past, this type of detail was not provided.

OPPS OCE
The current OPPS OCE:

• Processes claims for all outpatient institutional providers with the exception of hospitals not subject to OPPS;
• Performs detailed editing and evaluates patient data to help identify possible coding errors, returning a series of edit flags with claim/line item actions;
• Assigns Ambulatory Payment Classification (APC) numbers based on Healthcare Common Procedure Coding System (HCPCS) codes for payment under the OPPS; and
• Sets a series of indicators/flags based on various coding criteria and sends those indicators/flags to the OPPS Pricer to determine pricing.

Non-OPPS OCE
The current non-OPPS OCE:

• Processes claims for the following non-OPPS hospitals: Indian Health Service hospitals, critical access hospitals (CAHs), Indian Health Service hospitals (IHS)/Tribal hospitals including IHS/Tribal CAHs, Maryland hospitals, as well as hospitals located in American Samoa, Guam, or the Commonwealth of the Northern Mariana Islands;

• Processes claims from Virgin Island hospitals with dates of service January 1, 2002 and later, and from hospitals that furnish only inpatient Part B services with dates of service January 1, 2002 and later; and

• Does not perform detailed editing and grouping (unlike the OPPS OCE) since it is not required for these hospitals.

CR5344 provides instructions and specifications for the integrated OCE, which will be used to process outpatient claims for the following institutional providers:

• OPPS providers (hospital outpatient departments, Community Mental Health Centers (CMHC) and for limited services provided in a Home Health Agency (HHA) not under the Home Health Prospective Payment System, or to a hospice patient for the treatment of a nonterminal illness);

• Non-OPPS hospitals (Indian Health Service Hospitals, Critical Access hospitals (CAH)), Maryland hospitals, as well as hospitals located in American Samoa, Guam, or the Commonwealth of the Northern Mariana Islands. In addition, claims from Virgin Island hospitals with dates of service January 1, 2002 and later, and hospitals that furnish only inpatient Part B services with dates of service January 1, 2002 and later are edited in the non-OPPS OCE; and

• All non-hospital outpatient institutional providers (HHAs, Skilled Nursing Facilities, Rural Health Clinics, Federally Qualified Health Centers, Hospices, Renal Dialysis Facilities, Religious Non-Medical Healthcare Institutions, Comprehensive Outpatient Rehabilitation Facilities, and Outpatient Physical Therapy Providers).

The changes specific to the July release for the new integrated OCE will be issued in a separate recurring CR, which will replace the non-OPPS, and the OPPS recurring CRs for July. As a result, there will only be one recurring CR for each quarterly release of the OCE beginning with the July release.

Implementation
The implementation date for CR5344 is July 2, 2007.

Additional Information

For more complete details, especially regarding the edits of the integrated OCE, please see the official instruction (CR5344) issued to your intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1107CP.pdf    on the CMS Web site.

Current OCE Web-based training may be found under Medicare Payment Policy training at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1. If you have any questions, please contact your intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip   on the CMS Web site.

Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including --“It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot--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: MM5344
Pub. 100-4, Transmittal# R1107CP, CR# 5344
Related CR Release Date: November 9, 2006
Effective Date: July 1, 2007
Implementation Date: July 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.

Posted: 11/27/2006

CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.