Corporate Compliance

Revenue code edit in the OCE?

Medicare Insider, September 16, 2008

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As you can see by the number of items reported below, CMS was busy last week. One of the documents issued by CMS last week was a transmittal providing the Integrated Outpatient Code Editor (I/OCE) specifications for the third quarter. CMS typically reissues the I/OCE specifications with changes every calendar quarter. It is important that hospitals closely review each I/OCE transmittal. The revisions often require hospitals to make operational changes in order to remain in compliance with CMS billing requirements.

One thing that is interesting about the October I/OCE specifications is the addition of a new edit (edit #79) titled “Incorrect billing of revenue code with HCPCS code.” Edit 79 will result in claims being placed on RTP (“return to provider”) status.

Historically, CMS has been fairly flexible with respect to the assignment of revenue codes. In most cases, CMS allows hospitals to select whatever revenue code will result in an accurate matching of billed charges to costs as reported on the cost report. Consequently, at first blush, this new edit seems very significant.

However, if you study the transmittal carefully, you will find some additional information buried in Appendix M of the transmittal (page 43) indicating that the application of edit 79 is limited to the following billing scenarios:

  1. Revenue code 381 with HCPCS other than packed red cells (P9016, P9021, P9022, P9038, P9039, P9040, P9051, P9054, P9057, P9058), or
  2. Revenue code 382 with HCPCS other than whole blood (P9010, P9051, P9054, P9056).

So, as it turns out, this new edit is not nearly as broad as its title suggests.


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