Health Information Management

Take note of I/OCE edit interactions

APCs Insider, February 22, 2013

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The I/OCE edits are full of nuances and exceptions, so it’s important to understand how they interact. Take edits 18 (inpatient procedure), 45 (inpatient separate procedures not paid), and 49 (service on same day as inpatient procedure).

CMS designates certain services as inpatient-only, meaning that CMS has determined providers must perform those services on an inpatient basis. Don’t get physicians—or HIM directors for that matter—started on the inappropriateness of CMS making blanket clinical decisions that restrict how the physician practices medicine.
 When coders or billers report an inpatient-only procedure on an outpatient claim, they hit I/OCE edit 18. And CMS doesn’t reimburse for the service.
The AMA designates some inpatient-only codes as separate procedures in the CPT Manual. You might think that means coders can report them separately, but it really means that they are commonly performed as integral components of a total service or procedure and should not be reported in addition to the code for the total procedure or service.
In other words, coders should only report a separate procedure if it is not performed with a primary procedure that encompasses the “separate” one, or when it adds “appreciably to the time and/or complexity of the procedure.”
If coders trigger edit 18, they will also hit edit 49 and CMS will deny payment for everything else on the claim for that date of service.

However, if that inpatient only service happens to be a separate procedure with a status indicator T (significant procedure, multiple reduction applies), then

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