Each ICD-10-CM diagnosis code is edited for completeness and validity. ICD-10-CM diagnosis codes without a required fourth, fifth, sixth, or seventh digit are considered invalid. Codes are also checked to insure that they were valid at the time of the patient's visit. Date validity is checked using the From Date and Thru Date on the claim. If the diagnosis code is valid only on the Thru Date, all other diagnosis code edits (e.g., OCE Edits 002, 003, 005, etc.) are bypassed.
Example(s):
OCE Edit 001 will be returned when the following diagnosis codes are reported on a claim:
- A12.3 - invalid code
- A01.0 - invalid code
- 567.89 - invalid for service dates on or after October 1, 2005
APC Assistant:
Check the code lists in the Diagnoses Page for all codes valid for this time period. Any code not present on these lists will generate edit 001.
Indicates that the diagnosis code is inconsistent with the patient's age. Age categories are as follows:
- Newborn (age = 0)
- Pediatric (age = 0 to 17 years)
- Maternity (age = 12 to 55 years (prior to 10/1/2019))
- Maternity (age = 9 to 64 years (effective 10/1/2019))
- Adult (age > 14)
Example(s):
OCE Edit 002 will be returned when the following diagnosis codes are reported on a claim with an incorrect age:
- A33 - appropriate only for newborn patients
- G93.7 - appropriate only for pediatric patients
- O00.90 - appropriate only for maternity patients
- J61 - appropriate only for adult patients
APC Assistant:
Diagnosis codes that are specific to particular age groups are listed in the appropriate age category in the Diagnoses Page. These diagnoses will generate edit 002 if they are listed for a patient that is outside of the age range.
Indicates that the diagnosis code is inconsistent with the patient's sex. Effective April 1, 2010 (Version 11.1 OCE), this edit will not be applied to claims that contain condition code 45 (Ambiguous Gender Category).
Example(s):
OCE Edit 003 will be returned when the following diagnosis codes are reported on a claim with the incorrect sex:
- C53.8 - appropriate only for female patients
- Z98.52 - appropriate only for male patients
APC Assistant:
All the diagnosis codes that generate edit 003 for female patients are in the "Male" list in the Diagnoses page.
All the diagnosis codes that generate edit 003 for male patients are in the "Female" list in the Diagnoses page.
Identifies a diagnosis code that may signal a condition (generally some type of trauma) for which Medicare is the secondary payer.
Example(s):
- 80230 Mandible Fracture Open. S02609B is the ICD-CM-10 equivalent
- 90081 Injury External Jugular Vein. S15209A is the ICD-CM-10 equivalent.
ICD-10-CM external Causes of Morbidity codes are equivalent to ICD-9-CM “E-codes”. These codes describe the circumstances that caused an injury, not the nature of the injury. The ICD-10-CM codes are prefixed with V, W, X, or Y. These codes are not acceptable billed by themselves or as the principal diagnosis, however, they can be billed as the secondary diagnosis. If one of these codes is billed as a principal diagnosis, OCE Edit 005 will be issued, and the claim will be RTP.
Example(s):
OCE Edit 005 will be returned when the following diagnosis codes are reported on a claim as a principal diagnosis:
- Y83.9
- T40.7X5A
APC Assistant:
All ICD-10-CM diagnoses codes that generate Edit 005 are listed in the ICD-10-CM
"005-External Cause Code"
list located in the Criteria Drop-down on the Diagnosis page.
Each Level I or Level II procedure code is edited for completeness and validity. This OCE Edit indicates that the procedure code is invalid or was not valid for the patient’s dates of service. Date validity is verified using the From Date on the claim.
Effective October 01, 2011, this edit is suspended for UB-04 Bill Type 032X (Home Health Services Under a Plan of Treatment) claims containing Revenue Code 0023 (Home Health Prospective Payment System).
Effective April 01, 2017, this edit will no longer be issued for UB-04 Bill Type 032X claims that cross the calendar year if the procedure code is valid on the From Date or the Thru Date.
Example(s):
OCE Edit 006 will be returned when procedure code 15342 is reported on a claim.
APC Assistant:
Check the code lists from the Procedures page for all HCPCS codes valid for this time period. Any code not present will generate edit 006.
Effective January 01, 2016, line-level OCE 007 will be returned when the patient’s age is not within the assigned age range for the procedure code.
Note: OCE Edit 007 is for informational purposes only and has no impact on payment.
Example(s):
OCE 007 will be returned in any one of these scenarios:
- • Procedure code 42831, restricted to ages 12 to 124, is billed on a claim with a patient age of 11.
- • Procedure code 36557, restricted to ages 0 to 4, is billed on a claim with a patient age of 5.
APC Assistant:
Procedures that are restricted to a particular age range are shown with the allowed values in the “Min Age” and “Max Age” fields on the Procedures page.These procedures generate OCE 007 if they are provided to a patient whose age is outside of the permitted range. Procedures with no age restrictions are shown with an age range of 0-124.
Indicates that the HCPCS code is not valid for the patient's sex. Effective April 1, 2010 (Version 11.1 OCE), this edit will not be applied to claims that contain condition code 45 (Ambiguous Gender Category).
Example(s):
OCE Edit 008 will be returned when the following procedure codes are reported on a claim:
- 53430 - valid only for female patients
- 55250 - valid only for male patients
APC Assistant:
Procedures that generate edit 008 for female patients are listed in the "008-Female Only" list in the Procedures Page.
Procedures that generate edit 008 for male patients are listed in the "008-Male Only" list in the Procedures Page.
009: Non-Covered Under Medicare Outpatient Benefit for Reasons Other Than Statute (Line Item Denial)
This edit identifies services that are never paid under any Medicare outpatient benefit. A subset of the procedure codes assigned to a payment status of "E" (Non-Covered Service) and all 099X revenue codes submitted without a procedure code, and assigned to a payment status of "E" are subject to this edit.
Example(s):
OCE Edit 009 will be returned when the following procedure codes are reported on a claim:
- 69090
- V5011
APC Assistant:
All HCPCS codes that will generate edit 009 are listed in the "009-Non-Covered" list, located under "Criteria" in the Procedures Page.
Exception:
Effective January 1, 2017, this edit is not applied for code G0428, Collagen Meniscus Implant Procedure, with Status Indicator "E1".
Identifies services that are billed by a provider for a denial notice. Edit 010 is triggered when a claim is submitted with condition code 21, Request for Denial Notification.
Identifies non-covered services that are billed by the provider when a beneficiary requests a Medicare review for coverage. If a claim is submitted with a condition code 20, Request for FI/MAC Review, the claim is placed in suspension pending Medicare review to determine coverage.
Identifies procedures that are only covered by the Medicare program under certain medical circumstances.
Example(s):
OCE Edit 012 will be returned when the following procedure code is reported on a claim:
- 15833 - covered by Medicare only when medically necessary
APC Assistant:
All HCPCS codes that generate edit 012 are listed in the "012-Questionable" list located under "Criteria" in the Procedures Page.
Identifies separate payment for eligible services not provided by Medicare. OCE Edit 013 is returned when a claim line contains a procedure code assigned to Payment Status Indicator E2 (Items or Services for Which Pricing Information and Claims Data are Not Available).
Example(s):
OCE Edit 013 is returned when procedure code 90393 is billed on a UB-04 Bill Type 0131 claim.
APC Assistant:
All HCPCS codes that generate edit 013 are listed in the "013-Not Sep Pay" list located under "Criteria" in the Procedures Page.
Identifies codes that describe services not generally performed in the hospital outpatient setting. These services are not covered under outpatient PPS and include codes for home health services, rest home visits and hospice visits.
Examples(s):
- 59400 Routine Obstetric Care
- 99301 Annual Nursing Facility Assessment
OCE 015 was eliminated due to the creation of Medically Unlikely Edits (MUEs). In the EASYGroup™ Ambulatory Code Editor™ (ACE), OCE 015 is used for the MUE edit. This edit compares billed units against clinically reasonable upper limits on units for specific services.
For some services, the MUE maximum applies to the individual service line, while for others, it applies to the total number of units billed for the service on the day. The MUE Adjudication Indicator (MAI) identifies how the MUE maximum is applied.
MAI values:
- 1 = Line Level Edit. The Max Units value is the maximum for each line-item instance of the procedure code.
- 2 = Date of Service Edit. The Max Units value is the maximum for all line-item instances of the procedure code on a given day.
- 3 = Date of Service Edit. The Max Units value is the maximum for all line-item instances of the procedure code on a given day.
Note: This implementation of OCE 015 is an implementation specific to ACE to facilitate the reporting of MUE maximums. CMS applies MUE editing outside of their I/OCE Software; as such, OCE 015 does not return in the I/OCE Software.
Example(s):
Procedure code 99486 may be billed with a maximum of 4 units in an outpatient setting and has an MAI of 1. OCE 15 applies if 99486 is billed with more than 4 units on a single line. Units are not added across multiple lines.
Procedure code 85041 may be billed with a maximum of 1 unit in an outpatient setting and has an MAI of 3. If 85041 is billed with 2 units or with a single unit on multiple lines on a day, each instance of 85041 receives OCE 015.
APC Assistant:
Codes subject to OCE 015 have a "Max Units" value on the Procedures Page. Select the “UNITS” link to view the Max Units and MAI for the service. A Max Units value of "-" means there is no associated MUE for the HCPCS code. CMS assigns Max Units values of 0 to certain services (e.g., some inpatient-only services). These codes show an associated Max Units value of 0 in APC Assistant and will generate OCE 015 when billed with a unit of 1 or more.
Modifiers that identify a service as non-covered, denied, or otherwise exempt from OCE 015 are listed as “015-MUE Exempt” on the Modifiers page.
This edit identifies situations where more than one exclusively conditional bilateral service is reported for the same date of service and a modifier of 50 is not reported. An exclusively conditional bilateral code represents a service that can be, but is not always, performed bilaterally. When performed bilaterally a modifier of 50 must be used, and the entire service is paid at 150% of the fee for a non-bilateral service. (The first service is paid at 100% and the second at 50%.) This edit does not apply to inherently bilateral, independently bilateral or non-bilateral codes.
Note: CMS removed all codes from the "exclusively bilateral" list effective October 1, 2005. This change effectively eliminates edit 016 starting October 1, 2005 since this edit only applies to exclusively bilateral services.
Example(s):
66830 Secondary Cataract Removal is a conditionally bilateral procedure that Medicare considers to be "exclusively bilateral". If it appears more than once on the same claim for the same service date, and each times without the bilateral modifier, this will generate edit 016 on both claim lines.
Line-level OCE 017 identifies situations where bilateral procedures are incorrectly billed. This OCE identifies inherently bilateral procedures that are billed multiple times on the same day or with multiple units. Modifiers 76 and 77 indicate the procedure was repeated for a medically necessary reason. OCE 017 is not applied when each repetition of an inherently bilateral service is identified with modifier 76 or 77.
When billed on Critical Access Hospital (CAH) claims (i.e. UB-04 Bill Type 085X) containing professional services billed with UB-04 Revenue Code 096X, 097X, or 098X lines with professional revenue codes will be evaluated for OCE 017 separately from lines with facility revenue codes and will only receive the OCE when more than one unit is billed. Lines with facility revenue codes will receive the OCE when inherently bilateral procedures are billed multiple times on the same day or with multiple units.
Example(s):
OCE Edit 017 is returned when procedure code 11010 is billed on two different claim lines for the same service date.
APC Assistant:
All procedure codes that generate OCE 017 are listed in the "Inh-Inherent" list, located under Bil Ind on the Procedures page.
OCE 018 identifies inpatient-only procedures that Medicare believes can only be safely performed in an inpatient setting. Medicare does not pay for these procedures when they are performed in an outpatient setting.
Edits for inpatient procedures can result in a line-item denial (OCE 018) or a line-item rejection (OCE 045). OCE 018 is assigned to:
- 1.Inpatient-only procedures (identified by Payment Status Indicator C) that are not on the Separate Procedures List.
- 2.Inpatient-only procedures that are on the Separate Procedures List when no Payment Status Indicator T services are on the same date and no services assigned to Payment Status Indicator J1 are on the claim.
When OCE 018 is assigned, all other services provided on the same date are assigned OCE 049 (Service on same day as inpatient procedure) and denied for payment.
Inpatient-only services may be eligible for payment when Modifier CA (Procedure Payable Only in the Inpatient Setting When Performed Emergently on an Outpatient Who Expires Prior to Admission) is submitted on the line, and the discharge status indicates that the patient died or was transferred before the hospital could admit the patient.
Example(s):
OCE Edit 018 is returned when procedure code 00176 is reported on a UB-04 Bill Type 0131 claim.
APC Assistant:
Procedure codes relevant to this edit include:
- - Inpatient procedures codes are identified as "018-Inpatient Only" in the Criteria field on the Procedures page.
- - Separate inpatient procedures are identified as "045-Inpt Sep Proc" in the Criteria field on the Procedures page.
- - Payment Status Indicator T procedures are listed under “T - Procedure or Service, Multiple Reduction Applies” in the Pay Stat drop-down on the Procedures page.
- - Payment Status Indicator J1 services listed under “J1 - Services paid through a Comprehensive APC” in the Pay Stat drop-down on the Procedures page.
Mutually exclusive procedures cannot be billed together on the same claim for the same day. This edit is based upon Correct Coding Initiative (CCI) logic (see Industry Insight No. 40, Correct Coding Initiative (CCI)) and identifies the unpaid procedure of the mutually exclusive pair. The unpaid procedure of the mutually exclusive procedure pair is often but not always the more expensive procedure.
The presence of a modifier will not eliminate this error under any circumstances.
The effective dates of certain mutually exclusive code pairs are now different between the OCE and the CCI. The CCI changes for each quarter are implemented one quarter later in the OCE. So, for example, the V11.2 CCI edits, effective July 2005 for non-OPPS claims, were selectively implemented in the October 2005 OCE.
Example(s):
If CPT code 92607, For Speech Device RX 1 Hour, was reported with CPT code 92597, Speech Device Eval, CPT code 92597 would generate Edit 019.
Note: With the July 2012 IOCE, CMS has deactivated Edit 019 and combined it with Edit 020 retroactive to the beginning of the IOCE.
Identifies the column 2 code of a Column1/Column2 Correct Coding edit, indicating that this code should not be reported along with the column 1 code on the same service date. Often, the column 2 code is a component of a procedure that is billed on the same date as the comprehensive procedure. Services that are normally a component of a more comprehensive procedure cannot be billed separately, but must be considered as included in the more comprehensive procedure. This edit is also based on CCI logic.
The presence of a modifier will not eliminate this error under any circumstances.
The effective dates of certain Column 1/Column 2 code pairs are different between the OCE and the CCI. Prior to the V5.0 OCE, this edit was referred to as the Comprehensive/Component edit. This definition was expanded in the Correct Coding edits and subsequently in the OCE.
Example(s):
OCE Edit 020 is returned when the following procedure codes are both reported on a claim:
- 93015
- 93016
APC Assistant:
All OCE/CCI Column1/Column2 code pairs are listed in the "OCE/CCI Edit Pairs" page.
Identifies an evaluation and management (E&M) service that is billed on the same day as a surgical procedure (either an "S", significant procedure not discounted, or a "T", significant procedure eligible for discounting) and modifier 25 is not added to the E&M code. E&M codes are not normally reimbursed on the same day as a surgery or significant procedure. Modifier 25 signals that the physician performs additional services at the visit beyond those associated with the procedure.
Example(s):
OCE Edit 021 is returned when the following procedure codes are both reported on a claim:
- 10081
- G0402
APC Assistant:
All HCPCS codes that can generate edit 021 in the presence of a surgical procedure and the absence of modifier 25, are listed in the "V-Clinic or ED Visit" list located under "Pay Stat" in the Procedures Page.
Indicates that the two-character modifier associated with the HCPCS code is not valid for the service date or has never been valid according to OCE definitions.
Effective October 01, 2011, this edit is suspended for UB-04 Bill Type 032X (Home Health Services Under a Plan of Treatment) claims containing Revenue Code 0023 (Home Health Prospective Payment System).
Example(s):
OCE Edit 022 is returned when Modifier 60 (CMS deleted Modifier 60 effective April 1, 2002) is present on a claim with a service date after April 1, 2002.
APC Assistant:
All modifiers for this time period are listed in the Modifiers page. Any active modifier not present on this list will generate edit 022.
Identifies a "from," "thru" or line item service date that is not within the normal calendar range. In addition, this edit flags claims with a "from" date that is greater than the "thru" date, or with a missing line item service date with HCPCS code, or with line item service dates that are not within the claim's "from/thru" date range.
ACE maintains twenty-eight consecutive quarters of I/OCE data. This edit identifies claims billed outside of this time period.
Identifies claims or records where the only services billed were incidental. Incidental services are packaged under OPPS and are paid as part of another primary service or procedure performed.
This OCE is assigned when:
- 1. The claim contains only a combination of the following:
- - The claim includes packaged claim lines;
- - The claim includes invalid procedure codes;
- - The claim includes revenue code-only claim lines with invalid revenue codes;
- - The claim includes claim lines that have partial-information procedure codes flagged with a Procedure Validity Indicator of 3 (Procedure is Valid for Dates With Pending Editing and/or Grouping Information).
- 2. None of the lines on the claim are rejected or denied (refer to OCE 047).
- 3. Claim-level OCE 035 (Only Mental Health Education and Training Services Provided (RTP)) is not returned.
Example(s):
OCE 027 will be returned when only procedure code 00100 is reported on a claim.
APC Assistant:
All services classified by Medicare as incidental are included in the "N - Packaged/incidental service" list located under "Pay Stat" drop-down on the Procedures page. For claim lines without procedure codes, all revenue codes.
Identifies codes that are not reportable to Medicare for outpatient claims because Medicare requires an alternate code to be used. Usually the alternate is a HCPCS Level II code. Most, but not all, of the codes in this category have been assigned to the payment status of "E" (non-covered). After January 1, 2017, the codes in this category are assigned to the payment status of "E1" (non-allowed item or service)
Example(s):
OCE Edit 028 is returned when procedure code 61640 is reported on a claim.
APC Assistant:
All HCPCS codes that generate edit 028 are listed in the "028-Unacceptable" list located under "Criteria" in the Procedures page. To obtain a list of possible alternates for a specific code, follow the link under the "028-Unacceptable" in the criteria column for that code on the Procedures Page. Please note that not all codes have an alternative code.
Identifies a partial hospitalization/IOP claim that does not have a mental health diagnosis as the principal diagnosis. Partial hospitalization/IOP claims must include a mental health diagnosis as the principal diagnosis since this program is for patients who have a profound and disabling mental health condition. Any claim with UB-04 Bill Type 076x (Clinic - Community Health Center) or UB-04 Bill Type 013X (Hospital Outpatient) with Condition Code 41 or Condition Code 92 that does not have a principal diagnosis in the mental health range will receive this edit. Effective January 01, 2024, OCE 029 also applies to IOP claims (UB-04 Bill Type 013X or 076X with condition code 92).
Note: OCE 029 will not be returned when the principal diagnosis is a Code First diagnosis.
Example(s):
OCE 029 will be returned when only the following diagnosis code is reported on a partial hospitalization claim (UB-04 Bill Type 076X with Condition Code 41):
- • A00.0 with procedure code 90845
APC Assistant:
Check the valid ICD-10-CM diagnosis codes in the "029-Mental Health Diagnosis" list located under the "Other Criteria" drop-down on the Diagnoses page. Any code not listed will generate OCE 029 on a partial hospitalization claim.
Identifies a date of service on a partial hospitalization claim where mental health services were provided but that day does not have the required level of service for the partial hospitalization per diem payment. This level of service is required since partial hospitalization programs are designed to provide individualized, coordinated, comprehensive and multidisciplinary treatment. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 76x) claims only.
Partial hospitalization services are divided into two lists: list A and list B. List A contains extended, family and group psychotherapy services. List B contains all services on list A and all other types of psychotherapy services, neuropsychological testing services, activity therapy, occupational therapy and education and training services.
Edit 030 is assigned to a partial hospitalization claim where one of the following is true:
- 1. At least one, but less than three, partial hospitalization services are provided on a day, or
- 2. At least three partial hospitalization services are provided on a day, but the services provided do not include at least one service from list A.
Each day of a partial hospitalization claim that does not get edit 030 is potentially eligible to receive the partial hospitalization per diem payment for that day.
Note:
The following section of edit 30 is not active as of January 1, 2009.
Edit 030 may not appear on a claim, even if the above criteria are met, if all of the following are true:
- 1. There are more than 3 days of service on the claim.
- 2. At least 57% (4/7) of the days that the claim spans included partial hospitalization services.
- 3. At least 75% of the days that the claim spans meet the partial hospitalization service criteria listed above (i.e. at least 3 partial hospitalization services one of which is on list A).
If one of the occupational training codes listed above appears multiple times, or with units greater than one, on a particular date, that service is counted only once in determining eligibility for edit 030. Prior to the Version 5.0 OCE, activity training and education and training services appearing multiple times were also counted only once in determining eligibility for edit 030.
Example(s):
OCE Edit 030 is returned when a partial hospitalization claim (UB-04 Bill Type 076X) has a valid mental health principal diagnosis code but contains only procedure code 90845, Psychoanalysis.
Identifies a date of service where the patient received electroconvulsive therapy (ECT) or a surgical service (type "T", subject to multiple procedure discounting) on the same day as partial hospitalization services. The claim will be reviewed to determine if the partial hospitalization day is reasonable and necessary, taking into account the patient's condition. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only.
ECT is identified by APC 00320. The presence of an ECT service, or any service assigned to an APC with payment status of "T", on any date within a partial hospitalization claim, will generate an error 031 for the claim.
APC Assistant:
All HCPCS codes that group to APC 00320 are listed in the Procedures page. All HCPCS codes that are type "T" procedures are listed in the "T - Significant Proc, Discounted" list located under "Pay Stat" in the Procedures Page.
Combines edit 030 and 031 for partial hospitalization claims with "from" and "through" dates spanning two or three dates of service. For these claims, if one or more of the days qualifies for either edit 030 or 031, then the claim is also assigned edit 032. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only.
APC Assistant:
See edits 030 and 031.
Identifies a partial hospitalization claim with insufficient mental health services, where the claim spans more than three days. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only.
A claim with a claim span of more than three days, where less than four out of seven days (less than 57% of the days in the claim span) contain at least one partial hospitalization service, will be assigned edit 033.
In the context of this edit, claim span is defined as the earliest service date to the latest service date. For example, a claim with a "from date" of October 1st, and a "through date" of October 31st, but with services provided only on October 10th-20th, would have a claim span of eleven days in the context of this edit.
APC Assistant:
See edits 030 and 031.
Combines edit 030 and 031 for partial hospitalization claims with "from" and "through" dates spanning more than three days. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only.
This edit applies to any claim that spans more than three days, which does not meet the criteria for edit 033. (If a claim has been assigned edit 033, it is not eligible for edit 034). In the claim there must be an adequate number of days that do contain at least one partial hospitalization service, but in addition, at least 75% of those days must also contain the minimum level of partial hospitalization services required to qualify for the per diem payment. (This is the minimum level of services that will not generate edit 030 for the day.) If these conditions are not met, the claim will be assigned edit 034.
In the context of this edit, claim span is defined as the earliest service date to the latest service date. For example, a claim with a "from date" of October 1st, and a "through date" of October 31st, but with services provided only on October 10th-20th, would have a claim span of eleven days in the context of this edit.
APC Assistant:
See edits 030 and 031.
Edit 35 is assigned to any claim where the only services on the claim are classified as mental health education and training services. Edit 35 is not assigned to partial hospitalization claims, and does not require a mental health diagnosis.
Example(s):
OCE Edit 035 is returned for a two-day claim containing procedure code G0177 on day one and procedure code 92065 on day two. The second date with procedure code G0177 will receive OCE Edit 035.
APC Assistant:
The HCPCS codes that generate edit 035 in the absence of other outpatient psychiatric services are listed in the "035-MH Ed/Train" list located under "Criteria" in the Procedures Page.
Identifies dates of service where the patient received ECT or a surgical service (type "T", subject to multiple procedure discounting) and an extensive mental health service on the same day. This edit is similar to partial hospitalization edit 031, but applies only to mental health (non-partial hospitalization) claims. ECT is identified by APC 00320. Prior to April 1, 2003 two HCPCS codes were assigned to this APC: 90870 ECT Single Seizure and 90871 ECT Multiple Seizures. After April 1, 2003 only code 90870 was accepted.
Only procedures assigned to APCs 00323, 00324 or 00325 are considered "extensive" mental health services in the context of this edit.
The presence of a payment status "T" service alongside extensive mental health services does not trigger edit 036 unless the claim is eligible for the mental health per diem cap for that day. That is, where payment for mental health services for a particular service date exceeds the mental health per diem cap.
APC Assistant:
All HCPCS codes that group to APC 00320 are listed in the Procedures page. All HCPCS codes that are type "T" procedures are listed in the "T - Significant Proc, Discounted" list located under "Pay Stat" in the Procedures Page.
Identifies terminated procedures with a modifier of 50 (bilateral) or units greater than one (1). When a procedure is terminated, the first procedure that was planned should be reported with an appropriate modifier. Any other procedure should not be reported. Terminated procedures are identified with modifier 52 or modifier 73.
Example(s):
OCE Edit 037 is returned if a claim line contains procedure code 70030 with Modifier 73 and two units of service.
Identifies cases where a claim contains an implanted device but does not contain an appropriate matching procedure.
This edit is triggered whenever a payment status "H" or "U" item is present on a claim without a service assigned to payment status "S", "T", or "X" on the same date.
Example(s):
OCE Edit 038 is returned if a claim contains procedure code A9527 without any procedure codes that have a Payment Status Indicator of S, T, or J1.
APC Assistant:
All HCPCS codes that are designated as paystatus "H", "S", "T", "U" or "X" are listed under the appropriate payment status indicator list located under "Pay Stat" on the Procedures page.
Identifies a procedure code that is one of a pair of mutually exclusive procedures. Such procedures would not ordinarily be paid, but would be allowed if the appropriate modifier were present.
Only certain modifiers will override this edit. They are: 58, 59, 78, 79, and 91 for Level I. For Level II, they are E1-E4, F1-F9, FA, LC, LD, LT, RC, RT, T1-T9, and TA.
CCI changes for each quarter are implemented one quarter later in the OCE. So, for example, the V11.2 CCI edits, effective July 2005 for non-OPPS claims, were selectively implemented in the October 2005 OCE.
Example(s):
If 61001, Remove cranial cavity fl, were reported with 61000, Remove cranial cavity fl, without the appropriate modifier, 61000 would receive this edit.
Note: With the July 2012 IOCE, CMS has deactivated Edit 039 and combined it with Edit 040 retroactive to the beginning of the IOCE.
Identifies the column 2 code of a Column1/Column2 Correct Coding edit, indicating that this code should not be reported along with the column 1 code on the same service date. Often, the column 2 code is a component of a procedure that is billed on the same date as the comprehensive procedure. Services that are normally a component of a more comprehensive procedure cannot be billed separately, but must be considered as included in the more comprehensive procedure. This edit is also based on CCI logic.
Only certain modifiers will override this edit. They are 58, 59, 78, 79, and 91 for Level I. For Level II, they are E1-E4, F1-F9, FA, LC, LD, LT, RC, RT, T1-T9, and TA.
Prior to the V5.0 OCE, this edit was referred to as the Comprehensive/Component edit. This definition was expanded in the Correct Coding edits and subsequently in the OCE.
Example(s):
OCE Edit 040 is returned if procedure code 77412 is reported with procedure code 77402 without the appropriate modifier. The claim line with procedure code 77402 would receive this edit.
APC Assistant:
All OCE/CCI mutually exclusive code pairs are listed in the "OCE/CCI Edit Pairs" page. To view the modifiers than can override this edit, refer to the "NCCI Modifiers" list under "Category" on the Modifiers page.
The UB-04 revenue code reported was not valid for the receipt date of the claim or the claim line was submitted without a revenue code.
Effective with the V5.0 OCE, any claim lines which have no HCPCS code and an invalid revenue code are also assigned to payment status "W".
Note: In addition to identifying invalid revenue codes, the OCE groups revenue codes into four categories: non-covered, non-allowed, packaged, and other. Any claim line that contains only revenue code and charges - that is, any claim line without a HCPCS code - is slotted by the OCE into one of those four groups. Only those charges associated with revenue codes in the packaged group will be included in the pricing and payment calculations. This information is passed on to the APC Pricer, which determines which charges to include in its outlier payments and hold harmless adjustment calculations based on these categorizations.
Example(s):
OCE Edit 041 is returned for claims with UB-04 Revenue Code 0184 (Leave of Absence) with or without a procedure code.
APC Assistant:
Refer to the Revenue Codes page for a list of all valid revenue codes. Any code not on this list, or not valid as of the date of service, will generate edit 041.
A medical visit involves evaluation and management services, provided either in a clinic or in the emergency room. Under the OPPS, multiple medical visits cannot be billed with the same revenue center on the same date of service. Under this circumstance, if separate and unrelated services are provided during the second visit, providers are instructed to include condition code G0 (G plus zero) on the claim. If a claim does not have a condition code of G0, but has multiple medical visits on the same date and reported with the same revenue code, the OCE assigns Edit 042 to each of these services.
Example(s):
OCE Edit 042 is returned if a claim contains procedure code 92002 and procedure code 95250 on the same day with Revenue Code 0510 (Clinic General Classification). Both claim lines would receive OCE Edit 042.
APC Assistant:
All HCPCS codes that represent medical visits are listed in the "V - Clinic or ED Visit" list located under "Pay Stat" in the Procedures Page.
There are only a few codes used in the OCE to identify blood administration services. These include 36430 Blood Components Indirect Transfusion, 36440 Blood Push Transfusion <= 2 years and 36460, Intrauterine Transfusion. There are approximately 20 codes used in the OCE to identify blood products. These are in the ranges P9010-P9023 and P9050-P9059. These lists may be updated with each version of the OCE.
Example(s):
OCE Edit 043 is returned on a claim that has only procedure code 36430 and no blood administration procedure.
APC Assistant:
Blood administration services are listed in the 43-Blood Transfusion list located under "Criteria" on the Procedures Page. Blood products are listed in the 43-Blood Product list located under "Criteria" on the Procedures Page.
This edit identifies claim lines containing inappropriately coded observation room services. This edit is triggered if a claim line is assigned to a designated observation room revenue code, but does not contain one of the codes Medicare has identified as appropriate for observation room charge lines.
Example(s):
OCE Edit 044 is returned if a claim line has UB-04 Revenue Code 0762 (Treatment/Observation Room) and procedure code 73120.
APC Assistant:
Observation Room revenue codes can be identified from the "Observation Room" item under the "Category" drop-down on the Revenue Codes page. To obtain a list of observation room revenue code(s) refer to the Revenue Code page.
Observation Room services can be identified from the "044-Observation" item under the "Criteria" drop-down on the Procedures page.
Observation Room services can be identified from the "044-Observation" item under the "Criteria" drop-down on the Procedures page.
Medicare has established a list of procedures that it believes can only be performed safely in an inpatient setting. OCE 045 is assigned if an inpatient separate procedure is billed on the same date as a service with Payment Status Indicator T or on the same claim as a service with Payment Status Indicator J1. Under certain circumstances, OCE 045 may not be assigned when OCE 018 or the inpatient expired APC is assigned on the claim.
Medicare designated a sub-group of inpatient procedures as "Separate Procedures". Under certain circumstances these procedures trigger edit 045 instead of edit 018. If an inpatient procedure occurs on the "Separate Procedures" list, edit 045 will be assigned to this procedure as long as there is another service on the same date with a payment status indicator "T". Otherwise, if no payment status "T" procedure occurs on the same date, edit 018 will be assigned.
Example(s):
On a UB-04 Bill Type 0131 claim, OCE 045 is returned when inpatient-only procedure code 31725 is billed with procedure 27006 (assigned Payment Status Indicator J1). OCE 045 applies to the 31725 claim line
APC Assistant:
Procedure codes relevant to this edit include:
- - Separate inpatient procedures are identified as "045-Inpt Sep Proc" in the Criteria field on the Procedures page.
- - Inpatient procedures codes are identified as "018-Inpatient Only" in the Criteria field on the Procedures page.
- - Payment Status Indicator T procedures are listed under “T - Procedure or Service, Multiple Reduction Applies” in the Pay Stat drop-down on the Procedures page.
- - Payment Status Indicator J1 services are listed under “J1 - Services paid through a Comprehensive APC” in the Pay Stat drop-down on the Procedures page.
The purpose of this edit is to identify incorrect partial hospitalization claims. This edit is triggered if a claim with bill type 12X or 14X is submitted with condition code 41.
Example(s):
OCE Edit 046 is returned for a claim with UB-04 Bill Type 043X and Condition Code 41.
The purpose of this edit is to identify the claims with services that are not separately payable by Medicare.
Edit 047 occurs when a claim entirely consists of:
- One or more line item denials and/or rejections, and
- One or more line items classified as incidental or packaged. These claim lines include HCPCS codes with payment status indicators of "N", as well as packaged revenue codes reported with charges only (no HCPCS), also assigned to payment status "N". Edit 047 is assigned to each of these claim lines.
Example(s):
OCE Edit 047 is returned for a claim that has one line with procedure code 78351 and a second line with charges, no procedure code, and Revenue Code 0252 (Pharmacy Nongeneric Drugs). The line item with Revenue Code 0252 receives OCE Edit 047.
APC Assistant:
All services classified by Medicare as incidental are included in the "N - Packaged/Incidental Service" list located under "Pay Stat" in the Procedures Page. For lines without HCPCS codes, all revenue codes classified as "Packaged" are included in the "Packaged" list located under "Category" on the Revenue Codes page.
The purpose of this edit is to identify claim lines containing charges only (no HCPCS) with revenue codes that are not considered by the OCE to be packaged. If the revenue code is on a list of "non-covered" or "non-allowed" revenue codes, the charges associated with this line will be excluded from any outlier payments or hold harmless adjustment calculations.
Example(s):
OCE Edit 048 is returned for a claim with UB-04 Bill Type 0131 (Hospital Outpatient) and a claim line with both Revenue Code 0320 (Radiology Diagnostic General Classification) and no procedure code.
APC Assistant:
The non-covered revenue codes that generate edit 048 are listed in the "Non-Covered" list located under "Category" in the Revenue Codes page. The non-allowed revenue codes that also generate this edit are displayed in the "Non-Allowed" list located under "Category" in the Revenue Codes page. The revenue codes that will not generate edit 048 when submitted without a HCPCS code can be retrieved from the "Packaged" list located under "Category" in the Revenue Codes page.
The presence of a service on an outpatient claim which Medicare considers to be "inpatient only" causes Medicare to deny all services provided on the same
service date. Services provided on the same date as an "inpatient only" service are all assigned to edit 049, and flagged for line item denial. Since edit 018 initiates the assignment of edit 049, no other edits will be performed on lines with edit 049.
Example(s):
Old:
OCE Edit 049 is returned for claims containing procedure codes 00176 (Payment Status Indicator C) and 36514 (Payment Status Indicator S) with the same service date. OCE Edit 049 is assigned to the 36514 claim line.
APC Assistant:
All inpatient services are listed in the "C - Inpatient, Not Paid Under OPPS" list located under "Pay Stat" in the Procedures Page.
Separate inpatient procedures are listed in the "045-Inpt Sep Proc" list located under "Criteria" in the Procedures Page (see edit 045).
Certain services that are not covered under any Medicare outpatient benefit due to a statutory requirement are differentiated from the other non-covered services and assigned to OCE Edit 050. In addition, if Revenue Code 0637 is submitted without a procedure code, OCE Edit 050 is assigned.
Example(s):
OCE Edit 050 is returned for claims containing procedure code V5241.
APC Assistant:
All services that trigger edit 050 are listed in the "050-Non-Cov Stat Excl" list located under "Criteria" in the Procedures Page.
Effective January 01, 2016, line-level OCE Edit 051 will be returned when observation procedure code G0378, Hospital observation service, per hour, is reported more than once on a UB-04 Bill Type 013X or 085X claim. The first instance of observation procedure code G0378 on the claim will not receive OCE Edit 051, but subsequent instances of observation procedure code G0378 on the same claim will receive OCE Edit 051.
Example(s):
OCE Edit 051 is returned if procedure code G0378 is billed on two separate lines on a UB-04 Bill Type 013X claim. The claim line with the second instance of G0378 receives OCE Edit 051.
Prior to January 1, 2006: Observation services were eligible for additional payment under the OPPS in certain limited circumstances. These observation services were identified by HCPCS code G0244. This code was only allowed on a hospital outpatient claim if all of the following were true (See edits 056 and 057):
- One of the diagnoses on the claim had to be related to chest pain, congestive heart failure, or asthma. Medicare has specified a list of diagnoses that correspond to each condition. The diagnosis code can be in any position on the claim. The admit DX is also considered for this requirement.
- The units associated with G0244 had to be greater than or equal to 8 hours of observation. Less than 8 hours of observation services are not separately payable.
- There could not be a service with payment status "T" present on the claim with a service date equal to, or one day prior to, the G0244 service date.
As of January 1, 2006: Edit 052 is no longer active. However, requirements for separately payable observation services have not changed. Observation services are reported with new HCPCS code G0378 Hospital Observation Services per Hour. Observation services not meeting the hours, diagnosis or type "T" criteria of edit 052 will be packaged, rather than designated as separately payable, but edit 052 will no longer be assigned.
Example(s):
Any claim containing diagnosis code 4281 Left Heart Failure, is present on the claim in any position, along with G0244 with units less than 8 hours will generate edit 052.
January 1, 2006 and after: The HCPCS codes G0378 Observation Care by Facility, and G0379 Direct Admit to Observation, are not allowed on any claim except those with bill type 13X or 85X.
Example(s):
OCE Edit 053 is returned on a claim with a UB-04 Bill Type of 0341 (Home Health Services Not Under a Plan of Treatment) that contains procedure code G0378.
Note: The OBSCD drop down box does not show codes 60378 and 60379 except as a replacement REP code.
Historically, edit 054 identifies two codes that were not allowed to be coded together on the same day. Both codes received the edit. This edit involved only a small set of code pairs describing blood components.
HCPCS codes beginning with "C" (generally codes representing high tech pass-through devices) are created solely for use on OPPS outpatient claims. If a HCPCS code beginning with a "C" is submitted on a claim where the bill type is not 12X-14X, the claim is flagged with edit 055 and the claim is returned to the provider for correction.
Example(s):
OCE Edit 055 is returned on claims with a UB-04 Bill Type of 0341 (Home Health Services Not Under a Plan of Treatment) and procedure code C1760.
APC Assistant:
All HCPCS codes that generate edit 055 are listed in the "055-OPPS Specific Proc" list located under "Criteria" in the Procedures Page.
Edit 056 identifies claims where observation services are reported separately but without the required E&M services, and the service date was not the first day of any calendar year.
- The claim had to contain evaluation/management services or critical care services on the same date, or one day prior to, the G0244 service date. These services had to map to one of the following APCs:
-
00600 Low Level Clinic Visits
00601 Mid Level Clinic Visits
00602 High Level Clinic Visits
00610 Low Level Emergency Visits
00611 Mid Level Emergency Visits
0612 High Level Emergency Visits
00620 Critical Care Beginning in January 2003, a direct admit to observation for a patient with Asthma, CHF or chest pain was represented by the code G0263, on the same date as the G0244 service date to meet the E&M requirement, even though the services represented by this code are packaged. - Prior to January 1, 2005 only: In previous OCE releases for each condition (chest pain, congestive heart failure, asthma), Medicare had identified additional ancillary services that had to be on the claim with the same service date, or one day prior to, the G0244 service date.
As of January 1, 2006: Edit 056 is no longer active. However, requirements for separately payable observation services have not changed. Observation services are reported with new HCPCS code G0378 Hospital Observation Services Per Hour, and direct admission to observation is reported with new HCPCS code G0379 Direct Admission to Observation. Observation services that do not meet the evaluation and management criteria of edit 056 will be packaged, rather than designated as separately payable, but edit 056 will no longer be assigned.
Example(s):
A claim containing diagnosis code 4281 Left Heart Failure, was present on the claim in any position, along with G0244 with units equal to 24, but the claim did not contain an evaluation and management code with a service date equal to, or one day prior to, the G0244 service date, which is not equal to December 31 or January 1 of any year.
APC Assistant:
All evaluation/management APCs are classified as "O - E&M Service" under the "Criteria" drop-down on the APC page. For a list of procedure codes that group to an APC of interest, click the APC number and you will be transferred to the appropriate list from the Procedures page.
Edit 057 identifies claims where at least 8 units of observation services are reported on the first day of any calendar year without a service with payment status indicator T or J1 on the claim, and without the required E&M service on the same day or the day before.
Example(s):
OCE Edit 057 is returned on claims with procedure code G0378 billed with eight units and procedure code 95250 both billed on January 1st. OCE Edit 057 is assigned to the G0378 claim line. At least one payable service (not an E&M service) must also be billed on the same claim.
As of January 1, 2006, Edit 058 identifies claims where HCPCS code G0379 Direct Admit to Observation, is reported on a claim with bill type 13X but no HCPCS code G0378, Hospital Observation Services Per Hour.
Example(s):
OCE Edit 058 is returned on claims containing procedure code G0379 without procedure code G0378.
Edit 059 identifies claims where clinical trial services are present, but the ICD-9-CM code V707, Examination of Participant in Clinical Trial, is not submitted as the admitting diagnosis or a secondary diagnosis. Clinical trial services are represented by the following HCPCS codes:
G0292 Administration of Experimental Drug for Clinical Trial,
G0293 Non-Covered Surgical Procedure for Clinical Trial (Effective Before 7/1/03 only)
G0294 Non-Covered Procedure for Clinical Trial
G0293 Non-Covered Surgical Procedure for Clinical Trial (Effective Before 7/1/03 only)
G0294 Non-Covered Procedure for Clinical Trial
Edit 060 identifies claims in which modifier CA is used to identify an inpatient-only service performed on an emergency room patient who dies before being admitted or transferred. It cannot be used more than once for the same date on the same claim. Also, units must equal 1 for any service with the modifier CA.
Example(s):
OCE Edit 060 is returned for a claim where procedure code 62258 is billed with 2 units and Modifier CA.
This edit is new with the Version 5.0 OCE and is effective January 1, 2004. Edit 061 identifies codes representing non-implantable durable medical equipment that should be billed separately to the regional carrier (DMERC). These services are generally assigned to payment status code "Y".
Example(s):
OCE Edit 061 is returned on claims containing procedure code Q4074 billed to a Fiscal Intermediary (FI).
APC Assistant:
All HCPCS codes that generate edit 061 are classified as "061-DME" under the "Criteria" drop-down on the Procedures page.
This edit was new with the Version 5.0 OCE and became effective January 1, 2004. Edit 062 identifies codes that are not recognized by Medicare under the OPPS. Alternate, acceptable codes, usually Level II HCPCS codes, may be available for the same service. Most of the codes under this new edit were previously reported under Edit 028.
Example(s):
OCE Edit 062 is returned on claims containing procedure code 99183.
APC Assistant:
All HCPCS codes that generate edit 062 are classified as "062-Not Recognized" under the "Criteria" drop-down on the Procedures page. To obtain an alternate code(s) refer to the Procedures Page.
This edit was new with the Version 5.0 OCE and was implemented retroactively to August 1, 2000. Edit 063 identifies occupational therapy services on a non-partial hospitalization claim (for example, a standard bill type 13X with no condition code 41).
Example(s):
G0129 Occupational Therapy billed on a standard outpatient claim with bill type 131 without condition code 41 added to the claim would generate edit 063.
Note: With the January 2013 IOCE, CMS has deactivated Edit 063 effective January 1, 2013.
This edit was new with the Version 5.0 OCE and was implemented retroactively to August 1, 2000. Edit 064 identifies activity therapy services on a non-partial hospitalization claim (for example, a standard bill type 131 with no condition code 41).
Example(s):
G0176 Activity Therapy billed on a standard outpatient claim with bill type 131 without condition code 41 added to the claim would generate edit 064.
Note: With the January 2013 IOCE, CMS has deactivated Edit 064 effective January 1, 2013.
Certain revenue codes are not recognized by Medicare. Line items with these revenue codes are rejected for payment by Medicare.
Example(s):
OCE Edit 065 is returned on claims containing Revenue Code 0500 (Outpatient Services General Classification).
APC Assistant:
Revenue codes not recognized by Medicare can be identified from the "Not Recognized" item under the "Category" drop-down on the Revenue Code inquiry screen. To obtain a list of all revenue codes recognized by Medicare, refer to the Revenue Code Page.
This edit was new with the Version 5.2 OCE and was implemented retroactively to January 1, 2004. Services provided after FDA approval but prior to designation of a new HCPCS code are billed using HCPCS code C9399, Unclassified Drugs or Biologicals. This code causes a claim suspension so that the service can be manually priced based on 95% of the AWP. Supporting information including National Coverage Determination (NCD) code, units and date of service may be required in the remarks section of the claim.
Example(s):
OCE Edit 066 is returned for claims containing procedure code C9399, which represents a drug or biological that has received FDA approval, but has not yet been assigned a unique procedure code.
APC Assistant:
Codes which can be used to identify drugs or biologicals receiving FDA approval but not yet assigned unique HCPCS codes can be identified from the "066-Unclassified Drug/Bio" item under the "Criteria" drop-down on the Procedure Code inquiry screen.
This edit was new with the Version 5.2 OCE, and was implemented retroactively to January 1, 2004 and updated with the Version 6.1 OCE. Any new drug or biological which is provided after designation of a new HCPCS code but prior to FDA approval is flagged with edit 067 and denied for payment.
Example(s):
OCE Edit 067 will be returned for claims containing procedure code 90671 billed with service dates prior to the date in which FDA approval was received, which was July 16, 2021.
APC Assistant:
Codes subject to this edit are identified from the "067-FDA" item under the "Criteria" drop-down on the Procedures page.
This edit was new with the Version 6.0 OCE and became effective January 1, 2005. Any service which is provided prior to National Coverage Determination (NCD) approval is flagged with edit 068 and denied for payment.
Example(s):
OCE Edit 068 will be returned on claims containing procedure code G0011 billed on January 1, 2024, which is a valid service date prior to the date in which NCD or demonstration approval was received (January 02, 2024).
APC Assistant:
Codes subject to this edit are identified from the "068-NCD Coverage Date" item under the "Criteria" drop-down on the Procedures page. To obtain valid NCD approval dates for a specific service, enter the code on the Procedure page and click on the related "NCD" link under the criteria section.
This edit was new with the Version 6.0 OCE and was implemented retroactively to October 1, 2004. Specific services which are coded outside of a limited approval period are flagged with edit 069 and denied for payment.
Example(s):
OCE Edit 069 will be returned for claims containing procedure code G2000 billed outside of its approval period. This procedure code is approved for use under a clinical trial only during the time period of August 01, 2018 – December 31, 2026.
APC Assistant:
Codes subject to this edit are identified from the "069-Approval Range" item under the "Criteria" drop-down on the Procedures page. To obtain the valid date range for a particular code, click on the "APPROVE" link for that code under the "Criteria" heading.
Services which have been designated as inpatient only can be reimbursed when performed in the emergency room when the patient dies or is transferred prior to admission. In these cases, the service should be submitted with Modifier CA, but this modifier will not be accepted unless the patient discharge status code is set to 20 (Expired) or other discharge status codes indicating the patient was transferred.
Example(s):
OCE Edit 070 will be returned for claims containing procedure code 62258 because this code is an inpatient-only procedure. If performed in an emergency room on an outpatient basis and the patient dies prior to admission, the claim must include Modifier CA and discharge status 20. Otherwise, OCE Edit 070 will be generated.
This edit is new with the Version 6.1 OCE and is effective April 1, 2005 through December 31, 2014. Hospitals paid under the OPPS that report procedure codes that require the use of devices must also report the applicable HCPCS codes and charges for all devices that are used to perform the procedures. Device coding is necessary so that the OPPS payment for these procedures will be correct in future years. For October 2005 and again for January 2006, CMS made substantial changes to edit 071, significantly expanding the list of device/procedure pairs and adding a small set of procedures requiring two devices.
Example(s):
OCE Edit 071 is returned if procedure code 92982 is reported without procedure code C1725, C1874, C1876 or C1885.
This edit was new with the Version 6.1 OCE and became effective retroactive to January 1, 2005. Services assigned to payment status "M" cannot be billed to the Fiscal Intermediary or MAC, and claims containing these services will be returned to the provider for correction. Generally this edit relates to IV fusion, chemotherapy and chemotherapy assessment services provided by the physician.
Example(s):
OCE Edit 072 is returned on hospital outpatient claims containing procedure code 88291.
APC Assistant:
All HCPCS codes that generate edit 072 are classified as "072-Not Billable" under the "Pay Stat" drop-down on the Procedures page.
This edit was new with the Version 6.2 OCE and became effective July 1, 2005. If an OPPS provider pays for the actual blood or blood product itself, in addition to paying for processing and storage costs when blood or blood products are supplied by either a community blood bank or the OPPS provider's own blood bank, the OPPS provider must separate the charge for the blood product(s) from the charge for processing and storage services. The OPPS provider reports charges for the blood or blood product itself using Revenue Code series 038X with the appropriate blood product HCPCS code and HCPCS modifier BL. The OPPS provider reports charges for processing and storage services on a separate line using Revenue Code 0390, Blood Storage and Processing, General Classification, or 0399, Storage and Processing, Other, with the appropriate blood product HCPCS code and HCPCS modifier BL.
Whenever an OPPS provider reports a charge for blood or blood products using Revenue Code 038X, the OPPS provider must also report a charge for processing and storage services on a separate line using Revenue Code 0390 or 0399. Further, the same date, units, HCPCS code, and modifier BL must be reported on both lines.
Effective for services furnished on or after July 1, 2005, the OCE returns to providers any claim that reports a charge for blood or blood products using Revenue Code 038X without a separate line for processing and storage services using Revenue Code 0390 or 0399 and both lines must include the same line item date of service, units, and HCPCS code accompanied by modifier BL.
Example(s):
OCE Edit 073 is returned if procedure code P9010 is billed with Revenue Code 0381 (Blood Packed Red Cells), and there is not another line on the same claim with a matching date, units, procedure code, and Revenue Code 039X (Administration, Processing, and Storage for Blood and Blood Components), or if there is a matching line, but both claim lines do not include Modifier BL.
APC Assistant:
Blood products are listed in the "073-Blood Product" list located under "Criteria" in the Procedures Page.
This edit was new to the Version 7.3 OCE and was effective October 1, 2006. Identifies conditionally or independently bilateral services with a modifier 50 (bilateral) and units of service greater than one on the same claim line.
Effective January 1, 2008 (Version 9.0 of the OCE), critical access claims (bill type 85X) that contain conditional or independently bilateral codes with modifier 50 and more than one unit of service on the same line or multiple lines on the same day, with the same revenue code (either 96X, 97X, or 98X) will receive edit 74. If the bilateral service is billed with any other modifiers besides modifier 50, the service will be excluded from this special critical access edit 74 logic.
Example(s):
OCE Edit 074 is returned if procedure code 29345 is billed with Modifier 50, 2 units, and a service date on or after October 1, 2006.
APC Assistant:
All bilateral procedures are indicated on the Procedures Page under the "Bil Ind" column. The drop down menu "Bil Ind" allows for searches on conditional, independent, and inherent bilateral procedures.
This edit is new with the Version 8.0 OCE. Effective January 1, 2007 through December 31, 2013, this edit identifies claim lines where Modifier FB (item provided without cost to provider, supplier or practitioner) or Modifier FC (partial credit received for replaced device) is submitted for a service that is not assigned to Payment Status Indicators S, T, V, Q3, or X.
Effective January 01, 2014 through December 31, 2014, this edit identifies any claim line billed with Modifier FB or FC.
Example(s):
OCE Edit 075 is returned if procedure code 90655 is billed with Modifier FB.
APC Assistant:
Only procedures with a payment status of "S", "T", "V", "Q3" or "X" should have a modifier of FB or FC. To obtain a list of procedures by payment status select an option under the "Pay Stat" heading.
This edit is new with the Version 8.0 OCE and is effective January 1, 2007. It identifies line items where HCPCS code G0390 (Trauma response team associated with hospital critical care service) is billed without CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and without at least one claim line that contains revenue code 068X (Trauma response) on the same date of service.
Example(s):
OCE Edit 076 is returned if procedure code G0390 and procedure code 99291 are billed on the same date of service and Revenue Code 068X is not billed on any claim line.
This edit is new with the Version 8.1 OCE and is effective January 1, 2007 through December 31, 2014. Identifies certain devices billed without specific accompanying procedure codes.
Example(s):
OCE Edit 077 is returned if procedure code C1820 is billed without procedure code 61885, 61886, 63685, 64568, or 64590.
Medicare has determined that the costs of diagnostic radiolabeled products should be reported on the same claim with the associated nuclear medicine procedure. When a claim contains one of a specific list of separately payable nuclear medicine services, it must also contain at least one of a designated list of diagnostic or therapeutic radiolabeled products. This edit is not date specific; the radiolabeled product does not need to be on the same date as the nuclear medicine service. Also, there is not a one-to-one correspondence between specific nuclear medicine procedures and specific radiolabeled products. If a nuclear medicine service receives Edit 078, adding any diagnostic or therapeutic radiolabeled product on the list will correct the Edit.
Example(s):
OCE Edit 078 is returned if procedure code 78018 is billed without at least one HCPCS code representing a diagnostic or therapeutic radiopharmaceutical or brachytherapy source.
Note: With the January 2014 IOCE, CMS has deactivated Edit 078 effective January 1, 2014.
This edit is new with the Version 9.3 OCE and is effective October 1, 2008. This edit verifies that revenue code 381 is used only for the billing of packed red blood cells and that revenue code 382 is used only for the billing of whole blood.
Example(S):
OCE Edit 079 is returned for claims containing Revenue Code 0381 (Blood Packed Red Cells) that is not billed with a procedure code for packed red blood cells.
APC Assistant:
All HCPCS codes for packed red blood cells that can be billed with revenue code 381 are listed in the "079-Packed RBC" item located under the "Criteria" drop-down on the Procedures page. All HCPCS codes for whole blood that can be billed with revenue code 382 are listed in the "079-Whole blood " item located under the "Criteria" drop-down on the Procedures page.
This edit is new with the Version 9.3 OCE and is effective January 1, 2008. This edit verifies that mental health services which are not approved for the partial hospitalization program are not submitted on claims with a Bill Type 13X (hospital outpatient) and a Condition Code 41 (partial hospitalization), or claims with Bill Type 76X (community mental health centers).
Example(s):
OCE Edit 080 is returned on UB-04 Bill Type 0761 claims containing procedure code 0362T billed with Condition Code 41.
APC Assistant:
All HCPCS codes for mental health services that are not approved for the partial hospitalization program are listed in the "080-Not PHP Approved" item located under the "Criteria" drop-down on the Procedures page.
Effective January 1, 2009 (Version 10.0 of the OCE), certain psychotherapy services should only be provided as part of a partial hospitalization program and are not otherwise payable. If these services are submitted on a claim with a bill type of 13X and without condition code 41, the claim will be returned to the provider (RTP) with edit 81.
Example(s):
OCE Edit 081 is returned on UB-04 Bill Type 0131 claims containing procedure code G0129 billed without Condition Code 41.
APC Assistant:
All HCPCS codes for mental health services that are not payable outside the partial hospitalization program are listed in the "081-Only PHP Approved" item located under the "Criteria" drop-down on the Procedures page.
Effective January 1, 2009 (Version 10.0 of the OCE), if HCPCS code C9898, Radiolabeled product provided during a hospital inpatient stay, is billed with charges greater than $1.00, the claim will be returned to the provider (RTP) with edit 82.
Example(s):
OCE Edit 082 is returned when procedure code C9898 is billed with $1.02 in charges on the same date of service as the separately payable procedure code 31500.
If a service is provided on or after the effective date of NCD non-coverage and before the service is assigned to a non-covered payment status, the service is denied for payment (Line Item Denial) with Edit 083.
Note: Edit 083 is typically applied to services for very short time periods.
Example(s):
OCE Edit 083 will be returned on UB-04 Bill Type 0131 claims containing procedure code 87450 billed on or after October 06, 2020.
Effective January 1, 2012 through June 30, 2012, if HCPCS code C9732, Insertion of ocular telescope prothesis including removal of crystalline lens, and HCPCS code C1840, Lens, intraocular (telescopic), are not submitted together on the same day of service, the claim line will receive Edit 085 and the claim will be returned to the provider.
Effective July 1, 2012, if HCPCS code 0308T, Insertion of ocular telescope prothesis including removal of crystalline lens, and HCPCS code C1840, Lens, intraocular (telescopic), are not submitted together on the same day of service, the claim line will receive Edit 085 and the claim will be returned to the provider.
Example(s):
OCE Edit 085 is returned if procedure code 0308T is billed without procedure code C1840 on the same date of service.
Note: With the January 2014 IOCE, CMS has deactivated Edit 085 effective January 1, 2014.
If a manifestation diagnosis code is submitted as the principal diagnosis code, the principal diagnosis code will receive OCE 086, and the claim will be returned to the provider. This edit applies to UB-04 Bill Types 081X (Hospice (Non-Hospital Based)) and 082X (Hospice (Hospital Based)), effective October 01, 2014 and UB-04 Bill Type 032X (Home Health Services Under a Plan of Treatment), effective January 01, 2015.
Example(s):
OCE Edit 086 is returned on UB-04 Bill Type 0811 (Hospice (Non-Hospital Based)) claims containing ICD-10-CM diagnosis code D75.81 as the principal diagnosis.
APC Assistant:
All diagnosis codes that generate OCE 086 are listed in the 086-Manifestation Diagnosis list located under Other Criteria drop-down on the Diagnoses page.
This edit is effective January 1, 2014. Identifies certain devices billed without specific accompanying procedure codes.
Example(s):
OCE Edit 087 is returned on claims containing low-cost skin substitute application procedure code C5271 billed without a low-cost skin substitute product procedure code, such as Q4100.
APC Assistant:
Codes subject to this edit are identified using the following "Criteria" drop-down options on the Procedures page:
087-High Cost Skin Proc
087-Low Cost Skin Proc
087-High Cost Skin Prod
087-Low Cost Skin Prod
087-High Cost Skin Proc
087-Low Cost Skin Proc
087-High Cost Skin Prod
087-Low Cost Skin Prod
When at least one FQHC payment code is not reported on any day of a Federally Qualified Health Center (FQHC) claim (UB-04 Bill Type 077X (Clinic - FQHC) (not including UB-04 Bill Type 0770)), without Condition Code 65 (Non-PPS Claim), that includes other services, OCE Edit 088 will be issued, and the claim will be returned to the provider.
OCE 088 is not returned if each day on the claim meets at least one of the following conditions:
- An FQHC payment code is present.
- A chronic care service is present.
- A telehealth service (G2025 or Q3014) is present.
- An OUD treatment demonstration service is present and there is not an office-based OUD treatment service on the same day.
- Each service on the day receives OCE Edit 091.
- Effective January 01, 2024, when Condition Code 92 is used and there is a primary Intensive Outpatient Program (IOP) service on the claim.
Example(s):
OCE 088 is returned for UB-04 Bill Type 0771 claims containing an FQHC approved procedure code such as 92002 without an FQHC payment code.
APC Assistant:
The list of FQHC payment codes can be obtained from the "088/089-FQHC Pay Code" item under the "Criteria" drop-down on the Procedures page. The codes in the left hand column will display FQHC Payment Codes.
When a FQHC payment code is billed on a FQHC claim (UB-04 Bill Type 077X (not including UB-04 Bill Type 0770)), without Condition Code 65 (Non-PPS Claim)), without a qualifying visit code on the same day, the claim will receive OCE 089 and the claim will be returned to the provider.
Effective January 01, 2024, when a FQHC Intensive Outpatient Program (IOP) claim (UB-04 Bill Type 077X with Condition Code 92) is billed with an IOP primary service, then a payment code and qualifying visit are not required. However, if a payment code is provided and no qualifying visit is present, then E089 is returned.
Example(s):
OCE 089 is returned on claims containing FQHC payment code G0466 billed on an FQHC claim line by itself with procedure code 92012. Procedure code 92012 is not a qualifying visit code for payment code G0466.
APC Assistant:
The list of FQHC payment codes can be obtained from the "088/089-FQHC Pay Code" item under the "Criteria" drop-down on the Procedures page. This page will display acceptable Payment Code/Qualifying Visit pairings. The codes in the right hand column will display the FQHC Qualifying Visit codes.
Effective October 1, 2014, when a FQHC payment code is billed on a FQHC claim line (UB-04 Bill Type 077X (not including UB-04 Bill Type 0770), without Condition Code 65 (Non-PPS Claim)), without Revenue Code 0519 (Clinic Other), 052X (Free-standing Clinic General Classification) used on the G0466 line, OCE Edit 090 will be issued on the G0466 line and the claim will be returned to the provider.
Example(s):
OCE Edit 090 is returned on claims containing FQHC payment code G0466 and qualifying visit procedure code 92002 billed on an FQHC claim with Revenue Code 0270 (Medical/Surgical Supplies General Classification).
APC Assistant:
The list of FQHC payment codes can be obtained from the "088/089-FQHC Pay Code" item under the "Criteria" drop-down on the Procedures page. The codes in the left hand column will display FQHC Payment Codes.
OCE 091 is returned when a non-covered service is reported on a FQHC claim (UB-04 Bill Type 077X (not including UB-04 Bill Type 0770)), without Condition Code 65 (Non-PPS Claim)), or RHC claim (UB-04 Bill Type 071X). Non-covered services are Durable Medical Equipment (DME), laboratory services (except procedure code 36415), ambulance services, hospital-based care services, and non face-to-face services. OCE 091 is also returned on any line submitted with revenue code 29X (Durable Medical Equipment (Other than Renal)) or 54X (Ambulance General Classification).
Effective October 01, 2020, OCE 091 is returned on FQHC claims with Condition Code 65.
Effective January 01, 2024, OCE 091 is not returned on FQHC or RHC claims with Condition Code 92 (Intensive Outpatient Program(IOP)) for IOP services on the non-covered list.
Example(s):
OCE 091 is returned on FQHC claims containing procedure code Q0115.
APC Assistant:
Individual procedure codes subject to this edit are identified from the "091-FQHC Non-Covered" list under the "Criteria" drop-down on the Procedures page.
Effective January 01, 2015, this edit is returned when a device-intensive procedure code is reported without a device code on the same date of service. Effective January 01, 2019, certain device-intensive procedure codes billed with Modifier CG (Policy Criteria Applied) will not receive OCE Edit 092
Example(s):
OCE Edit 092 will be returned on claims containing procedure code 0221T billed without a device code.
APC Assistant:
Codes subject to this edit are identified from the 092-Device Required item under the "Criteria" drop-down on the Procedures page. To obtain a list of devices required for a particular procedure code, click on the 092-Device Required link under the "Criteria" heading for that procedure.
Effective January 1, 2016, this edit will be returned when procedure code V2785, Processing, preserving and transporting corneal tissue, is present without one of the cornea transplant procedure codes.
Example(s):
OCE Edit 093 is returned on claims containing procedure code V2785 without a cornea transplant procedure code.
APC Assistant:
Codes subject to this edit are identified from the 093-Corneal Proc item under the "Criteria" drop-down on the Procedures page.
Effective January 1, 2016, this edit will be returned when a biosimilar injection procedure code is billed without a corresponding biosimilar manufacturing modifier.
Example(s):
OCE Edit 094 is returned if procedure code Q5101 is reported without Modifier ZA.
Effective October 01, 2017, OCE 095 will be returned when a Partial Hospitalization Program (PHP) claim contains less than twenty total hours of qualified Partial Hospitalization (PH) services per a seven day period.
This OCE will sometimes be applied to the first and/or last week of a claim according to the last digit of the UB-04 Bill Type (as shown in table below).
| Last Digit of UB-04 Bill Type | OCEs Applicable to First Week | OCEs Applicable to Last Week |
|---|---|---|
| 1 (Admit through Discharge Claim) | No | No |
| 2 (Interim - First Claim) | No | Yes |
| 3 (Interim - Continuing Claim) | Yes | Yes |
| 4 (Interim - Last Claim) | Yes | No |
Effective July 01, 2019, this OCE applies on claim spans of seven days or more. For eligible UB-04 Bill Types, the admission week is considered the first week of the claim and the discharge week is considered the last full week of the claim. This OCE is not applied to partial weeks if the claim span is not divisible by seven.
Prior to July 01, 2019, if the claim span is not divisible by seven, the partial week is eligible for this OCE under the same rules as whole weeks. There is no minimum claim span to evaluate this OCE.
Note: OCE 095 is for informational purposes only and has no impact on payment.
Example(s):
OCE 095 is returned when procedure codes 90837, 90865, and G0411 are billed on the eighth day of a twenty-one day partial hospitalization claim.
This edit became effective on July 01, 2017 and was immediately terminated by CMS. OCE Edit 096 was to have been returned when a partial hospitalization interim claim contained From and Thru dates that spanned fewer than five days. A partial hospitalization interim claim is identified by UB-04 Bill Type 0763 (Clinic, Continuing Interim Claim) or UB-04 Bill Type 0133 (Hospital, Outpatient, Continuing Interim Claim) with Condition Code 41 (Partial Hospitalization Claim).
This edit became effective on July 01, 2017 and was immediately terminated by CMS. OCE Edit 097 was to have been returned when the From and Thru dates span more than seven days.
Effective January 01, 2016, OCE Edit 098 will be returned when a claim containing a pass-through device does not contain the required associated device-intensive procedure code on the same date of service.
Example(s):
OCE Edit 098 is returned when procedure code C1600 is reported on a claim without the associated device-intensive procedure on the same date of service.
APC Assistant:
Codes subject to this edit are identified from 098-Pass-Thru Device item under the "Criteria" drop-down on the Procedures page.
Effective January 01, 2016, OCE Edit 099 will be returned when a claim containing a pass-through (i.e., procedures with a Payment Status Indicator of G) or non-pass-through (i.e., procedures with a Payment Status Indicator of K) drug or biological does not contain an OPPS payable procedure (i.e., procedures with a Payment Status Indicator of J1, J2, P, Q1, Q2, Q3, R, S, T, U, or V). Additionally, Edit 099 will be returned only for those bill types that return APC information.
Example(s):
OCE Edit 099 is returned when procedure code J8655 is reported on a claim without an OPPS payable procedure.
APC Assistant:
Codes subject to this edit are identified from the 099-Excluded Drug/Bio item under the "Criteria" drop-down on the Procedures page.
Indicates that a claim reporting HSCT allogeneic transplantation (procedure code 38240) is reported and there is no additional line on the claim reporting required revenue code 815 for donor acquisition services.
Example(s):
OCE Edit 100 is returned when procedure code 38240 is reported on a claim that does not contain Revenue Code 0815 on any line.
Modifier PN is reported for an item or service that is considered to be non-excepted for an off-campus provider-based hospital outpatient department under Section 603. This Edit 101 will be issued when an Item or service reported with modifier PN is not allowed for payment under the Physician Fee Schedule (PFS). On claims of Bill Type 13X (Hospital, Outpatient), the PN modifier cannot be billed in conjunction with procedure codes assigned to Payment Status Indicator J2, and on claims of Bill Type 076X (Clinic, Community Mental Health), the PN modifier cannot be billed in conjunction with procedure codes assigned to Payment Status Indicator P (Partial Hospitalization Services).
In V18.1 (April, 2017), CMS retroactively updated Edit 101 to no longer apply to services assigned to a Comprehensive Observation APC with Payment Status Indicator J2 when billed on UB-04 Bill Type of 013X and without Condition Code 41. This change applies retroactively to January 1, 2017.
Example(s):
OCE Edit 101 is returned on UB-04 Bill Type 0761 with Condition Code 41 claims where procedure code 90832 is billed with 3 units and Modifier PN.
Effective January 01, 2017, CMS issued a list of modifier pairs (shown below in Table) that have conflicting definitions and should not be reported together. OCE Edit 102 will now be returned if any of these modifier pairs are billed on the same claim line.
| Modifier | Modifier | Effective Date |
|---|---|---|
| CT (Computed Tomography Services Furnished Using Equipment That Does Not Meet Each of the Attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 Standard) | FX (X-Ray Taken Using Film) | January 01, 2017 |
| PN (Non-Excepted Service Provided at an Off-Campus, Outpatient, Provider-Based Department of a Hospital) | PO (Excepted Service Provided at Off-Campus, Outpatient, Provider-Based Outpatient Department of a Hospital) | January 01, 2017 |
| CT | FY (X-Ray Taken Using Computed Radiography Technology/Cassette-Based Imaging) | January 01, 2018 |
| FX | FY | January 01, 2018 |
| ER (Items and Services Furnished by a Provider-Based Off-Campus Emergency Department) | PN | January 01, 2019 |
| ER | PO | January 01, 2019 |
Example(s):
OCE Edit 102 is returned if procedure code 99291 is billed with Modifiers PO and PN.
Effective July 1, 2017, OCE Edit 103 will be returned when a biosimilar modifier is billed with a biosimilar procedure code prior to the mid-quarter activation date, which is associated to the FDA approval.
Example(s):
OCE Edit 103 is returned if procedure code Q5102 and Modifier ZC are billed on or after July 1, 2017 and prior to the FDA approval date of July 24, 2017.
Effective April 01, 2018, OCE Edit 104 will be returned when procedure codes that are not eligible for the Rural Health Center (RHC) all-inclusive rate are billed with Modifier CG on a UB-04 Bill Type 071X (Clinic, Rural Health) claim.
Example(s):
OCE Edit 104 is returned if procedure code 36415 is billed with Modifier CG on a UB-04 Bill Type 071X claim.
APC Assistant:
Codes subject to this edit are identified from the "104-All-Inc Rate Not Elig" item under the "Criteria" drop-down on the Procedures page
Pass-through devices must be billed with a device-intensive procedure. Some pass-through devices have mid-quarter activation dates associated to FDA approval. Effective July 01, 2017, OCE Edit 105 will be returned when a pass-through device is billed prior to it?s FDA approval date with an appropriate device-intensive procedure.
Example(s):
OCE Edit 105 is returned if procedure codes C2623 and 36902 are billed with the following criteria:
- On the same day,
- On or after July 1, 2017,
- And prior to the FDA approval date of August 24, 2017.
APC Assistant:
Codes subject to this edit are identified from the "105-Device FDA Date" item under the "Criteria" drop-down on the Procedures page
OCE 106 is returned if an add-on code is billed without the necessary primary code(s). OCE 106 has four types:
Type 1: Effective April 01, 2018, a Type 1 add-on code must be billed on the same day or day after the required primary code(s).
Note: Type 1 add-on code editing for Critical Access Hospitals that have elected method II payment is performed separately for professional and facility service lines. Professional lines are identified with revenue codes in the 096X-098X range, while all other revenue codes identify facility service lines. A Type 1 add-on code on a CAH Method II claim must be billed on the same day or day after the required primary code(s), and the revenue code on the add-on code line must be the same type (professional vs. facility) as the revenue code(s) on the primary code line(s).
Drug Administration: Effective April 01, 2018, a drug administration add-on code must be billed on the same claim as the drug administration primary code.
Software as a Service (SaaS): Effective January 01, 2023, OCE 106 will be returned if an SaaS add-on code is billed without the primary procedure code on the same UB-04 Bill Type 013X (Hospital Outpatient) claim.
Remote Mental Health (RMH): Effective January 01, 2023, OCE 106 will be returned if an RMH add-on code is billed without the primary procedure code, on the same day, on a UB-04 Bill Type 013X claim (with or without Condition Code 41).
Example(s):
-
Type 1: OCE 106 is returned for a UB-04 Bill Type 022X (Skilled Nursing Facility) claim if procedure code 0076T is billed without primary procedure code 0075T on the same day or the day before.
-
Drug Administration: OCE 106 is returned if drug administration add-on code 96423 is billed without drug administration primary procedure code 96422 on the same UB-04 Bill Type 022X (Skilled Nursing Facility).
-
SaaS: OCE 106 is returned if SaaS add-on procedure code 0649T is billed without SaaS primary procedure code 0398T on the same UB-04 Bill Type 013X (Hospital Outpatient) claim.
-
RMH: OCE 106 is returned if RMH add-on procedure code C7902 is billed without RMH primary procedure code C7900 on the same day on a UB-04 Bill Type 013X (Hospital Outpatient) claim.
APC Assistant:
All procedure codes that generate OCE 106 are listed in the "106-Type I Add-on", "106-Drug Admin Add-on", "106-SaaS Add-on", and "106-RMH Add-on" lists located in the Criteria drop-down on the Procedures page.
107: Add-On Code Reported Without Required Contractor-Defined Primary Procedure Code (NOT SUPPORTED)
Please note, ACE™ is not supporting OCE Edit 107 (Add-On Code Reported Without Required Contractor-Defined Primary Procedure Code) at this time. This edit requires code pairs that include Type II add-on codes and contractor-defined primary codes. The contractor-defined primary codes have not been provided by CMS in the OCE data files. As such, Optum is unable to determine which primary codes would prevent the assignment of OCE Edit 107 when a Type II add-on code is billed.
Please note, ACE™ is not supporting OCE Edit 108 (Add-On Code Reported Without Required Primary Procedure or Without Required Contractor-Defined Primary Procedure Code) at this time. This edit requires code pairs that include Type III add-on codes and contractor-defined primary codes. The contractor-defined primary codes have not been provided by CMS in the OCE data files. As such, Optum is unable to determine which primary codes would prevent the assignment of OCE Edit 108 when a Type III add-on code is billed.
Effective October 01, 2018, OCE Edit 109 will be returned when a partial hospitalization claim (claims with a UB-04 Bill Type of 076X or 013X with Condition Code 41) is billed with a Code First diagnosis code as the principal diagnosis code, without a mental health diagnosis in the first secondary diagnosis position.
Example(s):
OCE Edit 109 is returned on UB-04 Bill Type 013X with Condition Code 41 claims containing principal diagnosis code T14.91XA and no other diagnosis codes.
APC Assistant:
All diagnosis codes that generate OCE Edit 109 are listed in the "109-Code First Diagnosis" list located in the Other Criteria drop-down on the Diagnosis page.
Effective July 01, 2018, OCE Edit 110 will be returned when a procedure code is billed after the effective date of the code, but prior to the initial marketing date of the item.
Example(s):
OCE Edit 110 is returned on claims containing procedure code Q5108 with a service date on or after July 1, 2018 and prior to its initial marketing date of July 12, 2018.
APC Assistant:
Codes subject to this edit are listed in the "110-Marketing Date" list under the Criteria drop-down on the Procedures page.
Effective January 01, 2018, OCE Edit 111 was added and is returned for any service used to identify a method used in manufacturing a drug or biological. These services are bundled into the total cost of the drug or biological and are not paid separately. Previously, these services received OCE Edit 062 (Code Not Recognized by OPPS; Alternate Code for Same Service May be Available).
In addition, OCE Edit 111 is returned when UB-04 Revenue Code 0870, 0871, 0872, or 0873 (Cell/Gene Therapy) is billed without a procedure code. The charges associated with the revenue center are bundled into the cost of the drug or biological.
Example(s):
OCE Edit 111 is returned if UB-04 Revenue Code 0870 is billed without a procedure code on a UB-04 Bill Type 0131 claim.
APC Assistant:
Codes subject to this edit are listed in the "111-Duplicative Bio Service" list under the Criteria drop-down on the Procedures page.
Effective January 01, 2020, line-level OCE Edit 112 is returned for any service that is identified as being non-covered and is meant for informational reporting purposes only.
Example(s):
OCE Edit 112 is returned if procedure code G1001 is reported on a UB-04 Bill Type 0131 (Hospital, Outpatient) claim on or after January 01, 2020.
APC Assistant:
All procedure codes that generate OCE Edit 112 are listed in the "112-Information Only" list located in the Criteria drop-down on the Procedures page.
Effective October 01, 2019, diagnosis-level OCE Edit 113 will be returned
when an unacceptable diagnosis code is billed as the principal diagnosis on a
claim.
Example(s):
OCE Edit 113 is returned if diagnosis code B95.0 (Streptococcus, Group A, as
the Cause of Diseases Classified Elsewhere) is billed as the principal
diagnosis code on a UB-04 Bill Type 0131 (Hospital, Outpatient) claim.
APC Assistant:
All diagnosis codes that generate OCE Edit 113 are listed in the "113-Unacceptable Primary Diagnosis" list located in the Other Criteria drop-down on the Diagnosis page.
Effective March 18, 2020, line-level OCE Edit 114 will be returned when
Modifier CS (COVID-19 Testing-Related Service) is reported on an item or
service that is not on the coinsurance waiver eligible list.
Example(s):
OCE Edit 114 is returned if Modifier CS is reported with procedure code
0001U, Red blood cell antigen typing, DNA, human erythrocyte antigen gene
analysis of 35 antigens from 11 blood groups, utilizing whole blood, common
RBC alleles reported, on a UB-04 Bill Type 0131 claim.
APC Assistant:
Procedure codes that are allowed to be reported with Modifier CS and will not generate OCE Edit 114 are listed in the "Coins Waived With Mod CS" list located in the Criteria drop-down on the Procedures page. All other procedure codes will generate OCE Edit 114 when reported with Modifier CS.
Effective January 01, 2021, line-level OCE Edit 115 will be returned when COVID-19 laboratory add-on procedure code U0005 is billed without primary procedure code U0003 or U0004 on the same date of service.
Example(s):
OCE Edit 115 is returned for a UB-04 Bill Type 0131 claim if procedure code U0005 is billed alone on the same day.
APC Assistant:
All procedure codes that generate OCE Edit 115 are listed in the "115-COVID-19 Lab Add-on" list located in the Criteria drop-down on the Procedures page.
Effective January 01, 2020, line-level OCE Edit 116 has been added and will be returned when an Opioid Treatment Program (OTP) service is not billed on the following claims:
- UB-04 Bill Type 013X (Hospital Outpatient) with Condition Code 89
- UB-04 Bill Type 085X (Critical Access Hospital) with Condition Code 89
- UB-04 Bill Type 087X (Freestanding Non-Residential Opioid Treatment Program)
- UB-04 Bill Type 013X (Hospital Outpatient) with Condition Code 89
- UB-04 Bill Type 085X (Critical Access Hospital) with Condition Code 89
- UB-04 Bill Type 087X (Freestanding Non-Residential Opioid Treatment Program)
Note: OCE Edit 116 only applies to UB-04 Bill Types: 012X (Hospital Inpatient (Medicare Part B Only)), 013X, 014X (Hospital-Laboratory Services Provided to Non-Patient), 071X (Clinic - Rural Health), and 077X (Clinic - Federally Qualified Health Center (FQHC)).
Example(s):
OCE Edit 116 is returned if procedure code G2067 is reported on a UB-04 Bill Type 0121 claim.
APC Assistant:
All procedure codes that generate OCE Edit 116 are listed in the "116-Opioid Treatment Program" list located in the Criteria drop-down on the Procedures page.
Effective July 01, 2021, line-level OCE Edit 117 will be returned when a drug procedure code is assigned a final Payment Status Indicator of K (Non PassThrough Drugs and Non-Implantable Biologicals, Including Therapeutic Radiopharmaceuticals) or G (Drug/Biological Pass-Through) and the charges are less than $1.01 and at least $0.01.
Example(s):
OCE Edit 117 is returned if procedure code 90371 is billed with charges of $1.00 on a UB-04 Bill Type 013X claim.
Effective October 01, 2014, claim-level OCE Edit 118 will be returned for UB04 Bill Types not supported by the I/OCE.
Example(s):
OCE Edit 118 is returned for a UB-04 Bill Type 0151 claim since this bill type is not supported by the I/OCE.
Effective October 01, 2014, claim-level OCE 119 will be returned when the claim's processing receipt date is invalid or falls outside of the supported date range. The claim's processing receipt date is the date the Payer received the claim and is used to validate revenue codes. If the receipt date is not supplied the Thru Date will be used. Effective April 01, 2017, this OCE will be returned when the claim’s processing Receipt Date is prior to the From Date.
Example(s):
OCE 119 is returned for a UB-04 Bill Type 013X claim with the receipt date of January 01, 2014.
Effective July 01, 2015, line-level OCE Edit 120 will be returned when a noncolorectal procedure code is billed with Modifier PT and a colorectal service is not billed on the same claim date. When a single colorectal service is billed with Modifier PT, OCE Edit 120 will not be returned.
Example(s):
OCE Edit 120 is returned for UB-04 Bill Type 085X claims that include procedure code 10005, billed with Modifier PT, and no other surgical procedure code on the same day.
APC Assistant:
All procedure codes that generate OCE Edit 120 are listed in the "120-Colorectal Proc" list located in the Criteria drop-down on the Procedures page.
Effective January 01, 2016, line-level OCE Edit 121 will be returned when a non-covered service, identified with Payment Status Indicator B, C, E, E1, E2, or M, is billed with an inpatient-only procedure code, assigned to a Comprehensive APC 5881, that indicates the patient expired in the emergency room prior to admission or was transferred.
Example(s):
OCE Edit 121 is returned for a UB-04 Bill Type 013X claim with Discharge Disposition 20 billed with procedure code 0352T and procedure code 62258 billed with Modifier CA.
Line-level OCE Edit 122 will be returned when a procedure code assigned to Payment Status Indicator G is billed with Modifier JG.
Example(s):
OCE Edit 122 is returned for a UB-04 Bill Type 013X claim with procedure code A9593 billed with Modifier JG.
Effective July 01, 2022, line-level OCE Edit 123 will be returned when a modifier is submitted on a date of service that is on or after the CMS-determined termination date.
Example(s):
OCE Edit 123 is assigned if Modifier CS (Cost Share Waiver COVID-19) is reported on or after May 12, 2023.
Effective July 01, 2022, line-level OCE Edit 124 will be returned when a procedure code is submitted on a date of service that is on or after the CMS-determined termination date.
Example(s):
OCE Edit 124 is assigned if procedure code G2023 is reported on or after May 12, 2023.
APC Assistant:
All procedure codes that generate OCE Edit 124 are listed in the "124-CMS Term Date" list located in the Criteria drop-down on the Procedures page.
Effective January 01, 2017, line-level OCE Edit 125 will be returned when an IMRT planning or delivery service is reported on a claim with the IMRT planning code.
Example(s):
OCE Edit 125 is assigned if procedure code 77014 is reported on the same claim as IMRT planning code 77301.
APC Assistant:
All procedure codes that generate OCE Edit 125 are listed in the "125-IMRT Planning" list located in the Criteria drop-down on the Procedures page.
Effective July 01, 2023, line-level OCE 126 will be returned when a telehealth modifier (95, GQ, or GT) is billed with a service that is not approved to be billed as telehealth on a UB-04 Bill Type 085X (Critical Access Hospital (CAH)) claim.
Example:
OCE 126 is assigned if non-telehealth procedure code 36455 is reported with telehealth modifier 95 on a UB-04 Bill Type 085X claim.
APC Assistant:
Procedure codes allowed to be billed with a telehealth modifier are listed in the "Telehealth" list located in the Criteria drop-down on the Procedures page. Any other procedure code billed with a telehealth modifier may be subject to OCE 126.
Effective July 01, 2023, line-level OCE 127 will be returned on claim lines that do not contain an allowable procedure code or revenue code on UB-04 Bill Type 012X (Hospital Inpatient (Medicare Part B Only)) claims. OCE 127 does not apply to claims billed with UB-04 Condition Code W2 (Duplicate of Original Bill).
Example:
OCE 127 is assigned if procedure code A9270 is reported with revenue code 0637 on a UB-04 Bill Type 012X claim.
APC Assistant:
All procedure codes allowable on a Part B Inpatient claim are listed in the "Part B Inpat Allowed" list located in the Criteria drop-down on the Procedures page. All revenue codes allowable on a Part B Inpatient claim are listed in the "Part B Inpat Allowed" drop-down on the Revenue Codes page.
Effective January 01, 2024, line-level OCE 128 will be returned for each claim line containing Intensive Outpatient Program (IOP) services when the minimum number of IOP services is not provided on a single day. A minimum of three IOP services must be billed on each day for claims with Condition Code 92 and UB-04 Bill Type is 013X (Hospital, Outpatient), 076X (Clinic- Community Mental Health Center) or 077X (Clinic - Federally Qualified Health Center (FQHC)).
Note: OCE 128 is for informational purposes only and has no impact on payment. Add-on IOP services are not counted toward the minimum requirement and these services do not receive OCE 128.
Example(s):
OCE 128 is assigned if procedure code 90832 is billed on a claim line with one unit and is the only IOP service provided on that day on a UB-04 Bill Type 013X claim with Condition Code 92.
APC Assistant:
All procedure codes classified as an IOP Service are listed in the "128-IOP Service" list located under the Criteria drop-down on the Procedures page.
Effective January 01, 2024, line-level OCE 129 will be returned when an IOP claim (UB-04 Bill Type 013X or 076X with Condition Code 92) contains less than nine hours of qualified IOP services per a 7 day period.
This OCE will sometimes be applied to the first and/or last week of a claim according to the last digit of the UB-04 Bill Type (as shown in table below).
| Last Digit of UB-04 Bill Type | OCEs Applicable to First Week | OCEs Applicable to Last Week |
|---|---|---|
| 1 (Admit through Discharge Claim) | No | No |
| 2 (Interim - First Claim) | No | Yes |
| 3 (Interim - Continuing Claim) | Yes | Yes |
| 4 (Interim - Last Claim) | Yes | No |
This OCE applies on claim spans of seven days or more. For eligible UB-04 Bill Types, the admission week is considered the first week of the claim and the discharge week is considered the last full week of the claim. This OCE is not applied to partial weeks if the claim span is not divisible by seven.
Note: OCE 129 is for informational purposes only and has no impact on payment.
Example(s):
OCE 129 is assigned if procedure code 90832 is billed on a claim line with three units on the eighth day of a twenty-one day IOP claim (UB-04 Bill Type 013X with Condition Code 92).
Effective January 01, 2024, line-level OCE 130 will be returned when Revenue Code 0905 and Modifier CG are billed on a line without a primary IOP service on an RHC IOP claim (UB-04 Bill Type 071X with Condition Code 92).
Example(s):
OCE 130 is assigned if procedure code 90791 is billed on a claim line with Modifier CG and Revenue Code 0905 on a UB-04 Bill Type 071X claim with Condition Code 92.
Effective January 01, 2024, line-level OCE 131 will be returned when less than three PHP service units are billed on a day of a PHP claim (UB-04 Bill Type 013X with Condition Code 41 or UB-04 Bill Type 076X with Condition Code 41).
OCE 131 is applied to each eligible PHP service on the day. PHP add-on codes are not counted toward the minimum of three PHP units and will not receive OCE 131.
Note: OCE 131 is for informational purposes only and has no impact on payment.
Example(s):
OCE 131 is assigned if procedure code 90832 is billed with one unit and is the only PHP service provided on the day on a UB-04 Bill Type 013X claim with Condition Code 41.
APC Assistant:
All procedure codes classified as a PHP Service are listed in the "131-PHP Service" list located under the Criteria drop-down on the Procedures page.
Effective January 01, 2024, line-level OCE 132 will be returned when a mental health service that is not approved for the Intensive Outpatient Program (IOP) is billed on an CMHC IOP claim (UB-04 Bill Type 076X with Condition Code 92).
Example(s):
OCE 132 is assigned if procedure code 0362T is billed on a UB-04 Bill Type 076X claim with Condition Code 92.
APC Assistant:
All procedure codes for mental health services that are not approved for the Intensive Outpatient Program are listed in the "132-Not IOP Approved" list located under the Criteria drop-down on the Procedures page.
Effective January 01, 2024, line-level OCE 133 will be returned when mental health services not payable outside the IOP are billed on certain non-IOP claim forms.
Example(s):
OCE 133 is assigned if procedure code G0129 is billed on a UB-04 Bill Type 013X claim without Condition Code 92.
APC Assistant:
All procedure codes for mental health services that are not payable outside the Intensive Outpatient Program are listed in the "133-Only IOP Approved" list located under the Criteria drop-down on the Procedures page.
Effective April 01, 2023, line-level OCE 134 will be returned when a procedure code is billed outside its designated approval period.
Example(s):
OCE 134 is assigned if procedure code 0001A is billed after the end of its approval period (on April 17, 2023 and prior to July 01, 2023) on a UB-04 Bill Type 013X claim with Condition Code 92.
APC Assistant:
All procedure codes that generate OCE 134 are listed in the "134-CMS Approval Period" list located under the Criteria drop-down on the Procedures page.
Effective January 01, 2024, line-level OCE 135 will be returned when certain device-intensive procedures are reported without a required device on the same day. This OCE is not returned if the device-intensive procedure is terminated early (Modifiers 52, 73, or 74).
Example(s):
On a UB-04 Bill Type 013X claim, line-level OCE 135 is assigned if device-intensive procedure code 0308T is billed without the appropriate device code C1840 on the same day.
APC Assistant:
Device-intensive procedures are listed in the "135-Device-Intensive Proc" list located in the Criteria drop-down on the Procedures page.
Effective January 01, 2024, claim-level OCE 190 will be returned when an IOP claim (UB-04 Bill Type 013X, 071X, 076X, or 077X claim with Condition Code 92) does not include an IOP primary service when other IOP services are billed on the same day. IOP claims must include an IOP primary service on each day that IOP services are provided.
Note: IOP services must be billed with Revenue Code 0905 (Psychiatric/ Psychological Treatments Intens Op Services - Psychiatric) to identify the service as IOP when reported on an FQHC IOP claim (UB-04 Bill Type 077X with Condition Code 92) or RHC IOP claim (UB-04 Bill Type 071X with Condition Code 92).
Example(s):
OCE 190 is assigned if procedure code 90791 is the only IOP service billed on a UB-04 Bill Type 013X claim with Condition Code 92.
APC Assistant:
All procedure codes that are classified as a IOP non-primary service are listed in the "190-IOP Non-Primary" list located under the Criteria drop-down on the Procedures page.
Effective January 01, 2024, claim-level OCE 191 will be returned when a PHP claim (identified with Condition Code 41 on a UB-04 013X or 076X claim) does not include at least one PHP primary service when other PHP services are billed on the same day. PHP claims must include a PHP primary service on each day that PHP services are provided.
Example(s):
OCE 191 is assigned if procedure code 90791 is the only PHP service billed on a UB-04 Bill Type 013X claim with Condition Code 41.
APC Assistant:
All procedure codes that are classified as a PHP non-primary service are listed in the "191-PHP Non-Primary" list located under the Criteria drop-down on the Procedures page.