| Description: |
The OPPS functionality of the Integrated Outpatient Code Editor (I/OCE) software was developed for the implementation of the Medicare outpatient prospective payment system mandated by the 1997 Balanced Budget Act. CMS released the proposed OPPS rules using the Ambulatory Payment Classification (APC) system in the September 8, 1998 Federal Register. Final regulations were published in the April 7, 2000 Federal Register and the system became effective for Medicare on August 1, 2000. Used in HL7 Version 2.x messaging in the GP1 segment.
The APC-based OPPS developed by CMS is the outpatient equivalent of the inpatient, DRG-based PPS. The APC system establishes groups of covered services so that the services within each group are comparable clinically and with respect to the use of resources.
Hospitals are required to use HCPCS when billing for outpatient services.
The OCE not only identifies individual errors but also indicates what actions should be taken and the reasons why these actions are necessary. In order to accommodate this functionality, the OCE is structured to return lists of edit numbers. This structure facilitates the linkage between the actions being taken, the reasons for the actions and the information on the claim (e.g., a specific diagnosis) that caused the action.
In general, the OCE performs all functions that require specific reference to HCPCS codes, HCPCS modifiers and ICD-10-CM diagnosis codes (ICD-9-CM diagnosis codes for historical claims with From Dates prior to 10/1/2015). Since these coding systems are complex and annually updated, the centralization of the direct reference to these codes and modifiers in a single program reduces effort and reduces the chance of inconsistent processing.
This is a CMS maintained list of edits: Please see the following for additional information:
• https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html
• https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/Background.htmlC
• https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.html |
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