- Integrated Outpatient Quarterly Release Files Version 20.1, Release, April, 2019
- Code Pairs Data for IOCE Quarterly Release Files.
- Integrated Outpatient Code Editor
- Outpatient Prospective Payment System
- Code Pairs IOCE
- OCE Claim Record
- Ambulatory Payment Classification (APC)
- CMS APC
Code Pairs for IOCE Quarterly Release Files
This dataset contains information about ‘integrated’ Outpatient Code Editor (I/OCE) program processes claims for all outpatient institutional providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as hospitals that are NOT (Non-OPPS). This dataset contains code pairs that should or should not be used together effective January, 2016.
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The ‘integrated’ Outpatient Code Editor (I/OCE) program processes claims for all outpatient institutional providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as hospitals that are NOT (Non-OPPS). A claim will be identified as ‘OPPS’ or ‘Non-OPPS’. Prior to OPPS, the software focused solely on editing claims without specifying any action to take when an edit occurred. It also did not compute any information for payment purposes. The OPPS functionality of the Integrated Outpatient Code Editor (I/OCE) software was developed for the implementation of the Medicare outpatient prospective payment system mandated by the 1997 Balanced Budget Act. CMS released the proposed OPPS rules using the Ambulatory Payment Classification (APC) system in the September 8, 1998 Federal Register. Final regulations were published in the April 7, 2000 Federal Register and the system became effective for Medicare on August 1, 2000.The APC-based OPPS developed by CMS is the outpatient equivalent of the inpatient, DRG-based PPS. The APC system establishes groups of covered services so that the services within each group are comparable clinically and with respect to the use of resources.
A claim will be identified as ‘OPPS’ or ‘Non-OPPS’ by passing a flag to the Outpatient Code Editor (OCE) in the claim record, 1=OPPS, 2=Non-OPPS; a blank, zero, or any other value is defaults to 1. These edits are updated quarterly and changes are communicated through Program Memorandum Transmittals.
The OCE not only identifies individual errors but also indicates what actions should be taken and the reasons why these actions are necessary. In order to accommodate this functionality, the OCE is structured to return lists of edit numbers. This structure facilitates the linkage between the actions being taken, the reasons for the actions and the information on the claim (e.g., a specific diagnosis) that caused the action. In general, the OCE performs all functions that require specific reference to HCPCS codes, HCPCS modifiers and ICD-9-CM diagnosis codes. Since these coding systems are complex and annually updated, the centralization of the direct reference to these codes and modifiers in a single program will reduce effort and reduce the chance of inconsistent processing.
About this Dataset
2018-07 to 2019-10
John Snow Labs; Centers of Medicare and Medicaid Services;
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Integrated Outpatient Code Editor, Outpatient Prospective Payment System, Code Pairs IOCE, OCE Claim Record, Ambulatory Payment Classification (APC), CMS APC
Integrated Outpatient Quarterly Release Files Version 20.1, Release, April, 2019, Code Pairs Data for IOCE Quarterly Release Files.
|Code1||1st Code in Pair||string||-|
|Code2||2nd Code in Pair||string||-|
|Add_On_Code||Add On Code Pair Flag (Add-on code is flagged if a code for a required primary procedure is not present on the same date of service.(Edit 84)||integer||level : Nominal|
|FQHC_Qualifying_Visit||Federally Qualified Health Center (FQHC) code pair flag (FQHC payment code [Code 1] is flagged if a code for the required qualifying visit [Code 2] is not present on the same date of service [Edit 89])||integer||level : Nominal|
|Device_Pair1||Procedure Code1 has a 1st required device Code2 (Edit 71 if an associated code2 is not present)||integer||level : Nominal|
|Device_Pair2||Procedure Code1 has a 2nd required device Code2 (Edit 71 if an associated code 2 is not present)||integer||level : Nominal|
|Device_Required_Procedure||Device Code1 has a required procedure Code2 (Edit 77 if an associated code2 is not present)||integer||level : Nominal|
|Device_Procedure_Bypass||Device Code1 can bypass procedure Code2 (if an associated code2 is not present)||integer||level : Nominal|
|Version_Compared||Current Version 75 = April, 2019||integer||level : Nominal|
|Start_Date||Effective date of “VER”||date||-|
|Code1||Code2||Add On Code||FQHC Qualifying Visit||Device Pair1||Device Pair2||Device Required Procedure||Device Procedure Bypass|