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Hospital Outpatient Prospective Payment System (OPPS) National Correct Coding Edits

IMPORTANT NOTICE:
The October 1st – December 31st 2014 issue of the Hospital OPPS will be the last issue distributed by NTIS.
Click here for further details.

Essential tool to ensure that your facility is coding OPPS claims correctly

 

 

NTIS is CMS's authorized distributor of the Hospital OPPS National Correct Coding Products

 

  Computer Products »

 

Hospital OPPS CCI ASCII Raw Data Files

SUB-5480

Hospital OPPS CCI Manual on searchable CD-ROM

SUB-5479

Paper Products

Hospital OPPS CCI Manual

SUB-5478

CPT codes only are copyrighted 2013 by the American Medical Association (AMA). All Rights Reserved. If you wish to reproduce any of the products listed, you must sign an agreement, or call 703-605-6015 for more information.

 

 

About the Products

  • The CCI edits contained in these products are specifically for Medicare Part B hospital outpatient services paid under the OPPS.
  • The Hospital OPPS National Correct Coding Initiative edits (NCCI) are used by Medicare Fiscal Intermediaries and are one calendar quarter behind National Correct Coding Initiative edits used by Medicare carriers.
  • The Hospital OPPS CCI edits are a modified subset of the National Correct Coding edits. 
  • The CCI edits are applicable to claims submitted on behalf of the same beneficiary for services provided to that beneficiary by the same hospital on the same date of service.
  • The edits address two major types of coding situations:
    • Column 1/Column 2 Correct Coding Edits (formerly Comprehensive/Component) apply to code combinations where one of the codes is a component of a more comprehensive code. The edit allows payment for the comprehensive code only.
    • Mutually exclusive codes are those codes that cannot reasonably be done in the same session. An example of a mutually exclusive situation is when the repair of the organ can be performed by two different methods. One repair method must be chosen to repair the organ and must be reported. A second example is the reporting of an "initial" service and a "subsequent" service. It is contradictory for a service to be classified as an initial and a subsequent service at the same time. CPT codes that are mutually exclusive of one another based either on the CPT definition or the medical impossibility/improbability that the procedures could be performed at the same session can be identified as code pairs. These codes are not necessarily linked to one another with one code narrative describing a more comprehensive procedure compared to the component code, but can be identified as code pairs that should not be reported together.
  • The hospital outpatient coding does not include CCI edits for the following: anesthesiology, evaluation & management, mental health, certain injections, derma bond, and computer-aided detection devices. 
  • Bypass modifiers and coding pairs in the OCE may differ from those in the NCCI because of differences between facility and professional services.

 

What is the difference between the Outpatient Code Editor edits and the CCI edits?

The OCE edits and the CCI edits are two editing systems used to process fiscal intermediary (hospital outpatient) and carrier-related claims, respectively. The CCI edits are developed based on coding conventions defined in the AMA's CPT Manual, current standards of medical and surgical coding practice, input from specialty societies, and based on analysis of current coding practice. The CCI edits are used for carrier processing of physician services under the Medicare Physician Fee Schedule while the OCE edits are used by intermediaries for processing hospital outpatient services under the Hospital OPPS.

The OCE is used in processing OPPS claims. Within the OCE are over 50 OCE edits, which determine whether a specific code is payable under the hospital OPPS. Many of the CCI edits are included in the OCE edits (see edit #19, 20, 39, and 40 below). The OCE edits are used exclusively under the hospital OPPS - they are not used within the Medicare Physician Fee Schedule.

The CCI edits always consist of pairs of HCPCS codes, and are arranged in two tables. One is the column 1/column 2 correct coding edits table, and the other is known as the mutually exclusive edits table. The OCE edits are arranged in numerical order with descriptions for each edit, as well as a claim disposition for each edit. Examples of OCE edits are listed below. For further information on the latest OCE edits within the hospital OPPS, please visit the CMS Web site at http://cms.hhs.gov/manuals/memos/comm_date_dsc.asp to find the latest transmittal (program memorandum) on the OCE.

 

  Edit               Description

Disposition

  1

Invalid diagnosis code

Return to Provider (RTP)

  2

Diagnosis and age conflict

RTP

  3

Diagnosis and sex conflict

RTP

  4

Medicare secondary payer alert

Suspend

19

Mutually exclusive procedure that is not allowed by CCI even if appropriate modifier is present

Line Item Rejection

20

Component of a comprehensive procedure that is not allowed by CCI even if appropriate modifier is present

Line Item Rejection

39

Mutually exclusive procedure that would be allowed by CCI if appropriate modifier were present

Line Item Rejection

40

Component of a comprehensive procedure that would be allowed by CCI if appropriate modifier were present

Line Item Rejection

 

 

Background information about Hospital Outpatient Prospective Payment System

Section 4523 of the Balanced Budget Act of 1997 (BBA) provides authority for CMS to implement a prospective payment system (PPS) under Medicare for hospital outpatient services, certain Part B services furnished to hospital inpatients who have no Part A coverage, and partial hospitalization services furnished by community mental health centers. The provisions of this section were further modified by sections 201 and 202 of the Balanced Budget Refinement Act of 1999 (BBRA).

All services paid under the new PPS are classified into groups called Ambulatory Payment Classifications or APCs. Services in each APC are similar clinically and in terms of the resources they require. A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC for an encounter.

Section 4523 of the BBA also changed the way beneficiary coinsurance is determined for the services included under the PPS. A coinsurance amount will initially be calculated for each APC based on 20 percent of the national median charge for services in the APC. The coinsurance amount for an APC will not change until such time as the amount becomes 20 percent of the total APC payment. In addition, Section 204 of the BBRA provides that no coinsurance amount can be greater than the hospital inpatient deductible in a given year.

Both the total APC payment and the portion paid as coinsurance amounts will be adjusted to reflect geographic wage variations using the hospital wage index and assuming that the portion of the payment/coinsurance that is attributable to labor is 60 percent.

CMS's final rule for the new system was published in the Federal Register on April 7, 2000 (65 FR 18434). The new system went into effect on August 1, 2000.

 

What is the Current Issue?
CMS issues a new version every three months. Each edition contains the latest billing information as authorized by CMS.

When filing claims from:

  • January 1 to March 31, 2014, you should use Version 20.0
  • April 1 to June 30, 2014, you should use Version 20.1
  • July 1 to September 30, 2014, you should use Version 20.2
  • October 1 to December 31, 2014, you should use Version 20.3

 

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