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Issue 2006-03, March 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications Version 7.0
Provider Types Affected
Providers billing Medicare fiscal intermediaries (FIs) and regional home health intermediaries (RHHIs) for services paid under the OPPS
Provider Action Needed
This article is based on Change Request (CR) 4238 which informs your FI that the January 2006 Outpatient Prospective Payment System Outpatient Code Editor (OPPS OCE) specifications have been updated with new additions, deletions, and changes.
Background
Change Request (CR) 4238 reflects specifications that were issued for the October revision of the OPPS OCE (Version 6.3). All shaded material in Attachment A of CR4238 reflects changes that were incorporated into the January version of the revised OPPS OCE (Version 7.0).
CR4238 provides the revised OPPS OCE instructions and specifications that will be utilized under the OPPS for hospital outpatient departments, community mental health centers (CMHCs), and for limited services when provided:
- In a Comprehensive Outpatient Rehabilitation Facility (CORF) or Home Health Agency (HHS) not under the Home Health Prospective Payment System; or
- To a hospice patient for the treatment of a nonterminal illness.
The modifications of the OPPS OCE for the January 2006 release (V7.0) are summarized in the table below. Readers should also examine the specifications attached to CR3583 and note the highlighted sections, which also indicate changes from the prior release of the OPPS OCE software.
Instructions for accessing the complete specifications are provided in the Additional Information section of this article. Note also that some of these modifications have an effective date earlier than January 1, 2006, and such dates are reflected in the “Effective Date” column.
Some OCE/APC modifications in the release may also be retroactively added to prior releases. If so, the retroactive date will appear in the “Effective Date” column. The modifications of the OCE/APC for the January 2006 release (V7.0) are summarized in the following table:
Summary of OPPS/OCE Modifications
# |
Modification Type |
Effective Date |
Edit |
Description |
1. |
Logic |
1/1/06 |
19/20, 39/40 |
Modify appendix F to apply CCI edits to bill types 22x, 23x, 34x, 74x and 75x (in addition to bill types 12X, 13X and 14X) |
2. |
Logic |
1/1/06 |
|
Add new Status Indictor “Q – Packaged services subject to separate payment based on criteria”; Payment Indicator = 3 |
3. |
Logic |
1/1/06 |
53, 57 |
Modify observation logic to package observation code (instead of claim RTP) when criteria for separate payment are not met; see Appendix H |
4. |
Logic |
1/1/06 |
52, 56 |
Deactivate observation edits 52 and 56 |
5. |
Logic |
1/1/06 |
57 |
Modify edit 57 to trigger only when the DOS for the observation code is January 1 |
6. |
Logic |
1/1/06 |
58 |
Modify logic for direct admission from physician’s office to pay a medical visit APC if observation is not payable; see Appendix H |
7. |
Logic |
1/1/06 |
|
Change SI from “T” to “S” for APC 375 (Inpatient-only procedure when patient expires before adm) |
8. |
Logic |
1/1/06 |
13,14 |
Deactivate edits 13 and 14 (SI/edit reassignment for code contents) |
9. |
Logic |
1/1/06 |
|
Modify partial hospitalization and mental health logic to remove editing for ECT or type “T” procedure on same day as partial hospital (level of) care; see Appendix C of Attachment A |
10. |
Logic |
1/1/06 |
31,36 |
Deactivate edits 31 and 36 |
11. |
Logic |
8/21/05 |
22 |
Implement a retroactive mid-quarter activation date for modifier CR – Catastrophe/Disaster Related |
12. |
Logic |
8/1/00 |
27 |
Change disposition for edit 27 to claim rejection, retroactive to 8/1/2000 |
13. |
Logic |
1/1/06 |
|
Implement 50% discounting for non-type “T” procedures with modifier 52; see Appendix D of Attachment A of CR4238 |
14. |
Logic |
1/1/06 |
|
Reassign SI to A (APC 0) for specified wound care codes when submitted with therapy revenue code (420, 430, 440) or therapy modifier (GN, GO, GP) |
15. |
Content |
|
|
Make HCPCS/APC/SI changes, as specified by CMS |
16. |
Content |
|
19,20 39,40 |
Implement version 11.3 of the NCCI file, removing all code pairs which include Anesthesia (00100-01999), E&M (92002-92014, 99201-99499), MH (90804-90911), or Drug Admin (96400-96450; 96542-96549; 90780,90781) |
17. |
Content |
|
17 |
Update bilateral procedure indicators in the OCE consistent with the Medicare Physician Fee Schedule (MPFS) |
18. |
Content |
4/1/05 |
71 |
Update procedure/device edit requirements |
19. |
Content |
|
|
Add/Delete modifiers as indicated by CMS |
20. |
Doc |
1/1/06 |
53 |
Change edit description to: “Codes G0378 and G0379 only allowed with bill type 13x” |
21. |
Doc |
1/1/06 |
57 |
Change edit description to: “E/M condition not met for separately payable observation and line item date for code G0378 is 1/1” |
22. |
Doc |
1/1/06 |
58 |
Change edit description to: “G0379 only allowed with G0378” |
23. |
Doc |
1/1/06 |
32 |
Change edit description to: “Partial hospitalization claim spans 3 or less days with insufficient services on at least one of the days” |
24. |
Content |
1/1/06 |
|
Codes G0008 and G0009, Flu and PPV administration, added to “vaccines” (see Appendix F footnote of Attachment A) |
| 25. |
Doc |
|
|
Change description for SI H to: “Pass-through device categories, brachytherapy sources, and radiopharmaceutical agents” |
26. |
Doc |
|
|
Change description of SI K to: “Non-pass-through drugs and biologicals” |
Implementation
The implementation date for the instruction is January 3, 2006.
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/R784CP.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 at http://www.cms.hhs.gov/apps/contacts/  on the CMS Web site.
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.
For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles.
Pub. 100-4, Transmittal# R784CP, CR# 4238
Medlearn Matters Number: MM4238
Related CR Release Date: December 16, 2005
Effective Date: January 1, 2006
Implementation Date: January 3, 2006
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