Health Information Management

October OPPS Update

APCs Insider, September 27, 2003

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September 5, 2003
Vol. 4, No. 35


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American Medical Billing Association
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Keith Siddel,
MBA, PhD (c),
president, CEO
HRM, Hospital Resource Management

Andrea Clark
Health Revenue Assurance Associates

Cheryl D'Amato,
director, health information management
HSS, Inc.

Julie Downey,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,

Julia R. Palmer
president, Health Information Management Division

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System




October OPPS update

The quarterly updates have been posted in PM A-03-076. Effective for services furnished on or after October 1, 2003, the following changes apply:

Click HERE for complete details of the PM.

Your APCs Weekly Monitor is a free weekly e-zine from HCPro, publisher of Briefings on APCs, the monthly newsletter devoted entirely to managing under APCs, and the newsletter, APC Answer Letter, with answers to readers' questions about coding for APCs.

The Monitor is a complimentary companion publication with a specific mission: to provide answers to your tough questions about the APC regulations.

If you have a question about APC coding that you would like addressed in the Monitor, post it on our Web site at Each week, our team of experts answers a question that will appeal to the majority of readers. The elected question and the corresponding answer are delivered to your inbox every Friday.

TODAY'S TOPIC: CCI edits and the OCE

Question: What Correct Coding Initiative (CCI) edits does the Outpatient Code Editor (OCE) contain? Does it remove certain edits, such as E/M visits? I realize CCI edits for the facility is always a version behind the professional. We have a claims editing system that edits based on CCI for facility v. OCE.

Answer: It is important that facilities use the OCE which couples the CCI edits within it. The CCI editor is only half the picture. Understanding the OCE will bring the picture into better focus.

The OCE currently incorporates 60 distinct edits under OPPS reimbursement methodology to identify claims issues for the provider. Many providers use claims scrubbers or APC groupers to identify problematic claims. The edits are resolved internally by designated personnel before the claims are submitted to the FI enabling the provider to receive its entitled reimbursement.

Within the 60 OCEs, four edits are dedicated to the CCI edits. They are:

  • Edit 19—mutually exclusive procedure that is not allowed by CCI even the appropriate modifier is present, resulting in line item rejection
  • Edit 20—Ccomponent of a comprehensive procedure that is not allowed by CCI even if the appropriate modifier is present, resulting in line item rejection
  • Edit 39—mutually exclusive procedure that would be allowed by CCI if the appropriate modifier were present, resulting in line item rejection
  • Edit 40—component of a comprehensive procedure that would be allowed by CCI if the appropriate modifier were present, resulting in line item rejection

As you mentioned, the CCI edits in the OCE are always one version behind the CCI edits used for physician billing. From dates of service of July 1 through September 30, hospitals will be using version 9.1 and on October 1 until the end of the year they will use version 9.2.

ASK THE EXPERT: Is it appropriate to code buddy taping as strapping? Is it appropriate to code rib belts as 21800, "closed treatment of rib fracture"?

Read HERE for the expert's answer!

TIP OF THE WEEK: Make sure coders and physicians meet face-to-face.

Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.

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