Diagnosis Codes Using DX10 Mapping for IOCE Quarterly Release Files

$199 / 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 the Valid Diagnosis codes for January, 2016.

Complexity

The 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

2016-01-11

Version

17

Update Frequency

Quarterly

Temporal Coverage

2016-01 to 2016-03

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, OCE Claim Record, Ambulatory Payment Classification (APC), CMS APC

Other Titles

Integrated Outpatient Quarterly Release Files Version 17.0, Release, January, 2016, Diagnosis Codes Mapping Data for IOCE Quarterly Release Files.

Name Description Type Constraints
DiagnosisDiagnosis Codestringrequired : 1
Lowest_Age_RestrictionCode valid for this age in years. The first value indicates the low age restriction for the code.integerrequired : 1 level : Nominal
Highest_Age_RestrictionCode valid for this age in years. The second value indicates the high age restriction for the code.integerrequired : 1 level : Nominal
Gender_CodeCode valid for this sexintegerrequired : 1 level : Nominal
Medicare_Secondary_Payer_Alertintegerrequired : 1 level : Nominal
E_CodeExternal cause of morbidity codeintegerrequired : 1 level : Nominal
Is_Mental_Health_DxMental Health diagnosisintegerrequired : 1 level : Nominal
Is_MalignancyMalignancy diagnosisintegerrequired : 1 level : Nominal
Manifestation_DiagnosisManifestation diagnosisintegerrequired : 1 level : Nominal
Code_DescriptionDiagnosis descriptionstringrequired : 1 maxLength : 60
DiagnosisLowest_Age_RestrictionHighest_Age_RestrictionGender_CodeIs_Medicare_Secondary_Payer_AlertIs_E_CodeIs_Mental_Health_DxIs_MalignancyIs_Manifestation_DiagnosisCode_Description
R0501240falsefalsefalsefalsefalseCough
A818101240falsefalsefalsefalsefalseKuru
R10830170falsefalsefalsefalsefalseColic
A7801240falsefalsefalsefalsefalseQ fever
B8601240falsefalsefalsefalsefalseScabies
K92101240falsefalsefalsefalsefalseMelena
L94601240falsefalsefalsefalsefalseAinhum
R11001240falsefalsefalsefalsefalseNausea
R23101240falsefalsefalsefalsefalsePallor
R29001240falsefalsefalsefalsefalseTetany