New Outpatient Facility Claims Edits

  • February 6, 2020

    In early March 2020, 3 Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) facility edits will be implemented on applicable ambulatory payment classifications (APCs) reimbursed hospital claims. These edits are identical to the Centers for Medicare and Medicaid Services (CMS) OCE edits for Medicare claims.

    Device-dependent procedure codes

    Device-dependent Healthcare Common Procedure Coding System (HCPCS) procedure codes are billed on an outpatient hospital claim and must have an associated device procedure code with the same date of service on the same claim.  If the device-dependent HCPCS procedure code is not billed this way, the device-dependent HCPCS procedure code will be denied reimbursement. Visit the CMS website for a list of device-dependent procedure codes.

    Pass-through/non-pass-through drugs or biologicals

    If a pass-through (status indicator G) or non-pass-through (status indicator K) drug or biological is billed without a payable procedure code (status indicator J1, J2, P, Q1, Q2, Q3, R, S, T, U, V), the drug or biological claim will be denied. Pass-through drugs and biologicals include radiopharmaceuticals, contrast agents, skin substitute products, and stress agents. HCPCS codes for blood-clotting factors are excluded from this edit. Lists of procedure codes with status indicator codes are located on the CMS website under Addendum B (refer to your Premera contract to find the applicable version to reference).

    Multiple Medical Visits Billed on the Same Day

    When multiple evaluation and management (E&M) procedure codes are billed with the same date of service and same revenue code on same or different claims, the condition code G0=Distinct Medical Visits is required to show distinct and independent visits. This condition code must be entered in fields 18-28 on the UB-04 claim form. When the condition code G0 is not entered to show the visits are distinct and independent visits, the claim will be denied reimbursement.

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