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Tip: Note new edits in I/OCE

APCs Insider, March 23, 2012

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CMS has added two new edits to the Integrated Outpatient Code Editor (I/OCE):

• 84 (Claim lacks required primary code [RTP])
• 85 (Claim lacks required device code or required procedure code [RTP])

Edit 84 creates an interesting interplay between two CPT® codes:

• 33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [including upgrade to dual chamber system])
• 33249 (Insertion or repositioning of electrode lead[s], for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator)

These codes have Q3 status (codes subject to ¬payment as part of a composite), but they are not truly composites. Code 33225 is an add-on code, so ¬facilities must bill it with the appropriate primary code. If a facility bills codes 33225 and 33249 together, CMS will pay only for 33249 and it will package 33225 into the payment. If a facility bills code 33225 with a different primary code, CMS will pay for both.

Edit 85 applies mainly to HCPCS codes C9732 (insertion of ocular telescope prosthesis including removal of crystalline lens) and C1840 (telescopic intraocular lens). Facilities should report these codes together. Billing one without the other will trigger the edit and prevent payment.

The only exceptions occur when the following ¬modifiers are appended:
• -52 (Reduced services)
• -73 (Procedures discontinued prior to anesthesia)
• -74 (Procedures discontinued after anesthesia administration or after the procedure has begun)

The tip is adapted from “CMS adds new modifier -PD, two edits, additional APCs” in the March issue of Briefings on APCs.

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