Code Pairs for IOCE Quarterly Release Files

$79 / year

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’ by passing a flag to the 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. This dataset contains code pairs that should or should not be used together effective January, 2016.

Complexity

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.
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.

Date Created

2016-01-11

Last Modified

2018-04-01

Version

19.1

Update Frequency

Quarterly

Temporal Coverage

2018-04 to 2018-06

Spatial Coverage

United States

Source

John Snow Labs => Centers of Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Integrated Outpatient Code Editor, Outpatient Prospective Payment System, Code Pairs IOCE, OCE Claim Record, Ambulatory Payment Classification (APC), CMS APC

Other Titles

Integrated Outpatient Quarterly Release Files Version 19.1, Release, April, 2018, Code Pairs Data for IOCE Quarterly Release Files.

Name Description Type Constraints
Code11st Code in Pairstringrequired : 1
Code22nd Code in Pairstringrequired : 1
Add_On_CodeAdd 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)integerrequired : 1 level : Nominal
FQHC_Qualifying_VisitFederally 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])integerrequired : 1 level : Nominal
Device_Pair1Procedure Code1 has a 1st required device Code2 (Edit 71 if an associated code2 is not present)integerrequired : 1 level : Nominal
Device_Pair2Procedure Code1 has a 2nd required device Code2 (Edit 71 if an associated code 2 is not present)integerrequired : 1 level : Nominal
Device_Required_ProcedureDevice Code1 has a required procedure Code2 (Edit 77 if an associated code2 is not present)integerrequired : 1 level : Nominal
Device_Procedure_BypassDevice Code1 can bypass procedure Code2 (if an associated code2 is not present)integerrequired : 1 level : Nominal
Code1Code2Add_On_CodeFQHC_Qualifying_VisitDevice_Pair1Device_Pair2Device_Required_ProcedureDevice_Procedure_Bypass
G046692002010000
G046692004010000
G046692004010000
G046692004010000
G046692004010000
G046692004010000
G046692004010000
G046692004010000
G046692004010000
G046692004010000