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About the Medicare Outpatient System (OPPS)

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Integrated Outpatient Code Editor -- Now Available

IMPORTANT NOTICE: Please read this important information regarding the IOCE

Essential tool for hospitals with outpatient billing to ensure claims are correct before submitted to Medicare for payment

 

NTIS is CMS's authorized distributor of the Integrated Outpatient Code Editor

 

     Electronic Reports

 

Description

Order Number

PC Software with free manual.

SUB-5486

Mainframe Software with free manuals

SUB-5487

Data Files

SUB-5488

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.

 

 

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). Claim will be identified as 'OPPS' or 'Non-OPPS' by passing a flag to the OCE in the claim record, 1=OPPS, 2=Non-OPPS; a blank, zero or any other value is defaulted to 1.

Technical Support
No technical support is available from CMS, 3M, or NTIS for these products. Only users that have technical resources to resolve any problems should purchase this product. For more information about the product, forward a request to kzuraf@ntis.gov.

Forward questions regarding OPPS policy directly to CMS to the following address:
OutpatientPPS@cms.hhs.gov

 

About the Software

This integrated version of the OCE processes claims consisting of multiple days of service. The I/OCE will perform three major functions:

  1. Edit the data to identity errors and return a series of edit flags.
  2. Assign an Ambulatory Payment Classification (APC) number for each service covered under OPPS, and return information to be used as input to a PRICER program.
  3. Assign an Ambulatory Surgical Center (ASC) payment group for services on claims from certain Non-OPPS hospitals.

Each claim will be represented by a collection of data, which will consist of all necessary demographic (header) data, plus all services provided (line items). It is the user's responsibility to organize all applicable services into a single claim record, and pass them as a unit to the I/OCE. The I/OCE only functions on a single claim record, and does not have any cross claim capabilities. The OCE will accept up to 450 line items per claim. The I/OCE software is responsible for ordering line items by date of service.

The I/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 I/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.

In general, the I/OCE performs all functions that require specific reference to HCPCS codes, HCPCS modifiers and ICD-9-CM diagnosis codes. Since these coding systems are complex and annually updated, the centralization of the direct reference to these codes and modifiers in a single program will reduce effort and reduce the chance of inconsistent processing.

This integration does not change current logic that is applied to outpatient bill types that already pass through the OPPS OCE software.

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, line items on claims from non-OPPS hospitals will be assigned specific edit numbers and dispositions, where in the past; this type of detail was not provided.

 

About the Medicare Outpatient Prospective Payment System
This software was developed for the implementation of the Medicare Outpatient Prospective Payment System (OPPS) for outpatient care. The basic unit of payment is an outpatient visit. The visit could represent one or more procedures, a medical evaluation, or ancillary services such as a chest x-ray or lab test.

Each Ambulatory Payment Classifications (APC) has a pre-established prospective payment amount associated with it. Multiple APCs can be assigned to one outpatient record. If a patient has multiple outpatient services during a single visit, the total payment for the visit is computed as the sum of the individual payments for each service.

Certain services (e.g., physical therapy, diagnostic clinical laboratory) are excluded from Medicare's prospective payment system for hospital outpatient departments. These services are exceptions paid under fee schedules and other prospectively determined rates.

 

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 15.0
  • April 1 to June 30, 2014 you should use Version 15.1
  • July 1 to September 30, 2014 you should use Version 15.2
  • October 1 to December 31, 2014 you should use Version 15.3