Bulletin: 05-205 - January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications Version 7.0

This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. Additional copies may be downloaded from our website at www.highmarkmedicareservices.com

Coming in 2006! Beginning January 1, 2006, Medicare prescription drug coverage will be available to people with Medicare. Health care professionals can find information about this new coverage at www.cms.hhs.gov/medlearn/drugcoverage.asp, on the CMS website.

Announcing the redesigned CMS web page dedicated to providing all the latest NPI news for health care providers! Visit http://www.cms.hhs.gov/NationalProvIdentStand/ on the web. This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation. A new fact sheet with answers to questions that health care providers may have regarding the NPI is now available on the web page; bookmark this page as new information and resources will continue to be posted.

For more information on private industry NPI outreach, visit the Workgroup for Electronic Data Interchange (WEDI) NPI Outreach Initiative website at http://www.wedi.org/npioi/index.html on the web.

CPT codes, descriptions and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature ,descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Related Change Request (CR) #: 4238
Related CR Release Date: December 16, 2005
Related CR Transmittal #: R784CP
Effective Date: January 1, 2006
Implementation Date: January 3, 2006

Providers Type Affected:

Providers billing Medicare fiscal intermediaries (FIs) and regional home health intermediaries (RHHIs) for services paid under the OPPS

Providers Action Needed:

This article is based on Change Request (CR) 4238 which informs your FI that the January 2006 Outpatient Prospective Payment System Outpatient Code Editor (OPPS OCE) specifications have been updated with new additions, deletions, and changes.

Background:

Change Request (CR) 4238 reflects specifications that were issued for the October revision of the OPPS OCE (Version 6.3). All shaded material in Attachment A of CR4238 reflects changes that were incorporated into the January version of the revised OPPS OCE (Version 7.0).

CR4238 provides the revised OPPS OCE instructions and specifications that will be utilized under the OPPS for hospital outpatient departments, community mental health centers (CMHCs), and for limited services when provided:

In a Comprehensive Outpatient Rehabilitation Facility (CORF) or Home Health Agency (HHS) not under the Home Health Prospective Payment System; or
To a hospice patient for the treatment of a non-terminal illness.

The modifications of the OPPS OCE for the January 2006 release (V7.0) are summarized in the table below. Readers should also examine the specifications attached to CR3583 and note the highlighted sections, which also indicate changes from the prior release of the OPPS OCE software.

Instructions for accessing the complete specifications are provided in the Additional Information section of this article. Note also that some of these modifications have an effective date earlier than January 1, 2006, and such dates are reflected in the Effective Date column.

Some OCE/APC modifications in the release may also be retroactively added to prior releases. If so, the retroactive date will appear in the Effective Date column. The modifications of the OCE/APC for the January 2006 release (V7.0) are summarized in the following table:

Summary of OPPS/OCE Modifications

#	Modification Type	Effective Date	Edit	Description
1.	Logic	1/1/06	19/20, 39/40	Modify appendix F to apply CCI edits to bill types 22x, 23x, 34x, 74x and 75x (in addition to bill types 12x, 13x and 14x)
2.	Logic	1/1/06		Add new Status Indictor Q Packaged services subject to separate payment based on criteria; Payment Indicator = 3
3.	Logic	1/1/06	53, 57	Modify observation logic to package observation code (instead of claim RTP) when criteria for separate payment are not met; see Appendix H
4.	Logic	1/1/06	52, 56	Deactivate observation edits 52 and 56
5.	Logic	1/1/06	57	Modify edit 57 to trigger only when the DOS for the observation code is January 1
6.	Logic	1/1/06	58	Modify logic for direct admission from physicians office to pay a medical visit APC if observation is not payable; see Appendix H
7.	Logic	1/1/06		Change SI from T to S for APC 375 (Inpatient-only procedure when patient expires before adm)
8.	Logic	1/1/06	13,14	Deactivate edits 13 and 14 (SI/edit reassignment for code contents)
9.	Logic	1/1/06		Modify partial hospitalization and mental health logic to remove editing for ECT or type T procedure on same day as partial hospital (level of) care; see Appendix C of Attachment A
10.	Logic	1/1/06	31,36	Deactivate edits 31 and 36
11.	Logic	8/21/05	22	Implement a retroactive mid-quarter activation date for modifier CR Catastrophe/Disaster Related
12.	Logic	8/1/00	27	Change disposition for edit 27 to claim rejection, retroactive to 8/1/2000
13.	Logic	1/1/06		Implement 50% discounting for non-type T procedures with modifier 52; see Appendix D of Attachment A of CR4238
14.	Logic	1/1/06		Reassign SI to A (APC 0) for specified wound care codes when submitted with therapy revenue code (420, 430, 440) or therapy modifier (GN, GO, GP)
15.	Content			Make HCPCS/APC/SI changes, as specified by CMS
16.	Content		19,20, 39,40	Implement version 11.3 of the NCCI file, removing all code pairs which include Anesthesia (00100-01999), E&M (92002-92014, 99201-99499), MH (90804- 90911), or Drug Admin (96400-96450; 96542-96549; 90780, 90781)
17.	Content		17	Update bilateral procedure indicators in the OCE consistent with the Medicare Physician Fee Schedule (MPFS)
18.	Content	4/1/05	71	Update procedure/device edit requirements
19.	Content			Add/Delete modifiers as indicated by CMS
20.	Doc	1/1/06	53	Change edit description to: Codes G0378 and G0379 only allowed with bill type 13x
21.	Doc	1/1/06	57	Change edit description to: E/M condition not met for separately payable observation and line item date for code G0378 is 1/1
22.	Doc	1/1/06	58	Change edit description to: G0379 only allowed with G0378
23.	Doc	1/1/06	32	Change edit description to: Partial hospitalization claim spans 3 or less days with insufficient services on at least one of the days
24.	Content	1/1/06		Codes G0008 and G0009, Flu and PPV administration, added to vaccines (see Appendix F footnote of Attachment A)
25.	Doc			Change description for SI H to: Pass-through device categories, brachytherapy sources, and radiopharmaceutical agents
26.	Doc			Change description of SI K to: Non-pass-through drugs and biologicals

Implementation:

The implementation date for the instruction is January 3, 2006.

Additional Information:

For complete details, please see the official instruction issued to your FI/RHHI regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/transmittals/downloads/R784CP.pdf on the CMS web site.

The Medlearn Matters article that corresponds to CR4238 can be reviewed at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4238.pdf on the CMS web site.

Assistance:

If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:

Maryland Providers: 1-866-488-0545
Pennsylvania Providers: 1-800-560-6170

Medicare Part A
(* = off-site link)

Search Part A

Electronic Mailing Lists

Providers Type Affected:

Providers Action Needed:

Background:

Implementation:

Additional Information:

Assistance:

Medicare Part A(* = off-site link)

Search Part A

Electronic Mailing Lists

Providers Type Affected:

Providers Action Needed:

Background:

Implementation:

Additional Information:

Assistance:

Medicare Part A
(* = off-site link)