Outpatient Code Editor (OCE) Clinical Edits

Transcription

1 TE TE Invalid diagnosis code = Medicare Default Diagnosis and age conflict = Health Plan will not apply this Diagnosis and sex conflict Changed from effective (process) date 8/7/2018 YES = Health Plan will apply this Medicare secondary payor alert E-code cannot be used as principal diagnosis Invalid code Procedure and age conflict Procedure and sex conflict Changed from effective (process) date 8/7/ Non-covered under any Medicare outpatient benefit, for reasons other than statutory exclusion Service submitted for denial (condition code 21) Service submitted for FI/MAC review (condition code 20) Questionable covered service Separate payment for services is not provided by Medicare Code indicates a site of service not included in OPPS Service units exceed maximum/medically Unlikely Edits YES YES Changed from effective Multiple bilateral s without modifier Inappropriate specification of bilateral Inpatient Changed from effective Mutually exclusive that is not allowed by NCCI even if appropriate modifier is present Page 1 of 8

2 TE TE Code 2 of a code pair that is not = Medicare Default allowed by NCCI even if appropriate modifier is present Medical visit on same day as a type T or S without = Health Plan will not apply this modifier Invalid Modifier YES = Health Plan will apply this Invalid Date Date Out of OCE Range Invalid Age Invalid Sex Changed from effective (process) date 8/7/ Only Incidental Services Reported Code not recognized by Medicare for outpatient claims; alternate code for same service may be available Partial hospitalization service for non-mental health diagnosis Insufficient services on day of partial hospitalization Partial hospitalization on same day as ECT (electroconvulsive therapy) or type T Partial hospitalization claim spans 3 or less days with insufficient services on at least one of the days Partial hospitalization claim spans more than 3 days with insufficient number of days meeting PHP services Page 2 of 8

3 TE TE Partial hospitalization claim spans more than 3 days with insufficient number of days meeting partial hospitalization criteria = Medicare Default Only mental health education and training services provided Extensive mental health services provided on day of ECT (electroconvulsive therapy) or type T Terminated bilateral or terminated with units greater than Inconsistency between implanted device or administered substance and implantation or associated = Health Plan will not apply this YES = Health Plan will apply this Changed from effective Mutually exclusive that would be allowed by NCCI if appropriate modifier were present Code 2 of a code pair that would be allowed by NCCI if appropriate modifier were present Invalid revenue code Multiple medical visits on same day with same revenue code without condition code G Transfusion or blood product exchange without specification of blood product Observation revenue code on line item with non-observation HCPCS code Inpatient separate s not paid Partial hospitalization condition code 41 not approved for type of bill Changed from effective Changed from effective Page 3 of 8

4 TE TE Service is not separately payable = Medicare Default Revenue center requires HCPCS code Service on same day as inpatient Non-covered under any Medicare outpatient benefit, based on statutory exclusion Multiple observations overlap in time Observation does not meet minimum hours, qualifying diagnoses, and/or type T conditions = Health Plan will not apply this Changed from effective YES = Health Plan will apply this Changed from effective Codes G0378 and G0379 only allowed with bill type 13x Multiple codes for the same service Non-reportable for site of service E/M condition not met and line item date for observation code G0244 is not 12/31 or 1/ Composite E/M condition not met for observation and line item date for code G0378 is 1/ G0379 only allowed with G Clinical trial requires diagnosis code V707 as other than primary diagnosis Use of modifier CA with more than one not allowed Service can only be billed to the DMERC Code not recognized by OPPS; alternate code for same service may be available Page 4 of 8

5 TE TE OT (occupational therapy) code = Medicare Default only billed on partial hospitalization claims AT (activity therapy) service not payable outside the partial = Health Plan will not apply this hospitalization program Revenue code not recognized by Medicare YES = Health Plan will apply this Code requires manual pricing Service provided prior to FDA approval Service provided prior to date of National Coverage Determination (NCD) approval Service provided outside approval period CA modifier requires patient status code Claim lacks required device code Changed from effective Service not billable to the Fiscal Intermediary/MAC Incorrect billing of blood and blood products Changed from effective Units greater than one for bilateral billed with modifier Incorrect billing of modifier FB or FC Trauma response critical care code without revenue code 068X and CPT Claim lacks allowed code Claim lacks required radiolabeled product Incorrect billing of revenue code with HCPCS code Changed from effective Changed from effective Page 5 of 8

6 TE TE Mental health code not approved for partial hospitalization program = Medicare Default Mental health service not payable outside the partial hospitalization program Charge exceeds token charge ($1.01) Service provided on or after effectiveective date of NCD noncoverage Claim lacks required primary code. Claim has been returned to the provider Claim lacks required device code or required code. Claim has been returned to the provider = Health Plan will not apply this YES = Health Plan will apply this Manifestation code not allowed as principal diagnosis. Claim has been returned to the provider Skin substitute application without appropriate skin substitute product code FQHC payment code was not reported for FQHC Claim FQHC claim lacks required qualifying visit code Incorrect revenue code reported for FQHC payment code Item or Service not covered under FQHC PPS Device-dependent reported without device code Corneal tissue processing reported without cornea transplant Changed from effective Changed from effective Changed from effective Page 6 of 8

7 TE TE Biosimilar HCPCS reported = Medicare Default without biosimilar modifier Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service = Health Plan will not apply this Partial hospitalization interim claim from and through dates must span more than 4 days Partial hospitalization services are required to be billed weekly Claim with pass-through device, drug or biological lacks required Claim with pass-through/non-passthrough/biological lacks OPPS payable Claim for HSCT allogenic transplant lacks required revenue code line for donor acquisition services Item or service with modifier PN not allowed under PPS Modifiers PO/PN not allowed on the same line Modifier reported prior to FDA approval date Service not eligible for all-inclusive rate Claim reported with pass-through device prior to FDA approval for the Add-on code reported without required primary code Add-on code reported without required contractor-defined primary code YES = Health Plan will apply this Changed from effective Changed from effective new new new new new new new Page 7 of 8

8 OCE OCE Description OPPS (APC) non-opps (non-apc) TE TE Add-on code reported without required primary or required contractor-defined primary code new = Medicare Default = Health Plan will not apply this YES = Health Plan will apply this Page 8 of 8