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CCI diligence is crucial for OPPS

APCs Weekly Monitor, January 9, 2004

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QUESTION: I have noticed that there is a discrepancy between the Outpatient Code Editor (OCE) version 9.3 and the current Correct Coding Initiative (CCI) physician version regarding the "no modifier allowed" edit with Q0081/90784. What has the Centers for Medicare and Medicaid (CMS) done to address this problem and what should my facility do to prevent mistakes?

ANSWER: For the first time, CMS has posted the specific CCI edits applicable to OCE on its Web site. CLICK HERE to view them.

In addition to using the CCI version that is one quarter behind the one that is applicable to physician services, (Version 9.3 began January 1, 2004) CMS "turns off" several edits in CCI to make a customized version that is applicable to outpatient hospital services in the OCE.

Those "turned off" edits have been summarized by CMS as "All CCI edits will be incorporated in the [OCE] with the exception of anesthesiology, evaluation and management, mental health, and dermabond."

However, there are several specific edits beyond those in the above statement that CMS has turned off. Most notably, Q0081/90784-no modifier allowed, an edit in the physician version of 9.3 that is missing from the OCE version. CMS admits it has moved beyond the above statement to selectively remove certain edits that are inappropriate for hospital services.

This is good news, particularly for providers concerned about the Q0081/90784-no modifier allowed edit. However, it is a potential reason for concern regarding hospital software vendors.

Many hospital patient accounting and health information management coding systems rely on the vendors of these systems to provide the proper updates. Unfortunately, some vendors merely download the CCI version (perhaps the wrong version) and include it in their software, not making the necessary changes in the edits for hospitals. Some vendors instruct clients in how to manually remove edits, but to do so "at their own risk." Other vendors include both versions in their software, but coders are not instructed in the difference. Furthermore, including both versions often slows coding functions.

Hopefully, vendors will understand the distinction between the hospital CCI version and the physician version. To help them gain this level of understanding, hospitals should work closely with their vendors to ensure the correct version is loaded into the edit software the hospital uses.

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