Healthcare Common Procedure Coding System Mapping Quarterly 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). Claims 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 defaulted to 1. These edits are updated quarterly and changes are communicated through Program Memorandum Transmittals. This dataset contains HCPCS Codes differences between October, 2015 and January, 2016.

Complexity

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

2018-01-01

Version

2018-01-01

Update Frequency

Quarterly

Temporal Coverage

2016-01 to 2018-01

Spatial Coverage

United States

Source

John Snow Labs => Centers of Medicare and Medicaid Services (cms.gov)

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

HCPCS Codes Mapping for IOCE, IOCE Quarterly Release Files V 17.0, HCPCS, HCPCS CPT, HCPCS Coding, HCPCS Coding System, HCPCS Age Restrictions, Healthcare Common Procedure Coding System, Hickpicks

Other Titles

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

Name Description Type Constraints
TypeIdentifies the type of differencestring-
HCPCSHealthcare common procedure coding systemstring-
Ambulatory_Payment_ClassificationAssignment for healthcare common procedure coding systemstring-
Status_IndicatorStatus indicator for healthcare common procedure coding systemstring-
Payment_IndicatorPayment indicator code for healthcare common procedure coding systemintegerlevel : Nominal
Gender_CodeGender Code 0 = not applicable, 1 = male, 2 = femaleintegerlevel : Nominal
Max_Units_Allowedintegerlevel : Nominal
Questionable_ServiceQuestionable covered service (Edit 12)integerlevel : Nominal
Service_Not_Paid_By_MedicareService not paid by Medicare (Edit 13)integerlevel : Nominal
Not_Recognized_By_MedicareNot recognized by Medicare for OPPS (Edit 28)integerlevel : Nominal
Is_Conditional_BilateralConditional bilateral codeboolean-
Is_Independent_BilateralIndependent bilateral codeboolean-
Inherent_Bilateralintegerlevel : Nominal
ComprehensiveNumeric rank for primary comprehensive APC procedureintegerlevel : Nominal
ComponentProfessional component = 0 & technical component = 1integerlevel : Nominal
Is_Activity_TherapyActivity therapy in the nursing interventions classification, a nursing intervention defined as the prescription of and assistance with specific physical, cognitive, social, and spiritual activities to increase the range, frequency, or duration of an individual'sboolean-
Is_Occupational_TherapyOccupational therapy (OT) is the use of assessment and intervention to develop, recover, or maintain the meaningful activities, or occupations, of individuals, groups, or communitiesboolean-
NonCovered_ServiceNon-covered service (Edit 9)integerlevel : Nominal
Not_Included_In_OPPSNot included in OPPS (Edit 14)integerlevel : Nominal
Is_AddOnAddon HCPCS codes if requiredboolean-
VaccineA vaccine is a biological preparation that provides active acquired immunity to a particular diseaseintegerlevel : Nominal
AntigenAntigen, substance that is capable of stimulating an immune responseintegerlevel : Nominal
SplintA strip of rigid material used for supporting and immobilizing a broken bone when it has been setintegerlevel : Nominal
CastStretch fabric cast and splint covers of various designs/colours for people that want to keep their castor splint cleanintegerlevel : Nominal
Deductible_NADeductible not applicableintegerlevel : Nominal
Blood_ServiceBlood transfusion or exchange (Edit 43)integerlevel : Nominal
Blood_ProductBlood product (Edit 43)integerlevel : Nominal
PHP_ServiceCode applicable for Partial Hospitalization logicintegerlevel : Nominal
DescriptionHCPCS code descriptionstring-
Exclusive_BilateralRelating to two sidesintegerlevel : Nominal
Lab_PathLaboratory/Pathology codes (Edit 15)integerlevel : Nominal
Sometimes_TherapySometimes therapy” codes outside a therapy plan of careintegerlevel : Nominal
Trauma_RevCode_RequiredTrauma revenue code for HCPCSintegerlevel : Nominal
Critical_Care_Requires_TraumaCritical care code for HCPCSintegerlevel : Nominal
STV_PackagedCode packaged when S,T, or V procedure presentintegerlevel : Nominal
Separate_ProcedureRequired separated procedure for reportingintegerlevel : Nominal
Statutory_ExclusionStatutoryExclusion code (Edit 50)integerlevel : Nominal
Hourly_ObservationHourly observation services HCPCS code G0378integerlevel : Nominal
Direct_Admit_ObsDirectly admitted to observation codesintegerlevel : Nominal
Not_Recognized_By_OPPSNot recognized by Medicare for OPPS (Edit 28)integerlevel : Nominal
DME_OnlyBill to DMERC only (Edit 61)integerlevel : Nominal
Unclassified_DrugUnclassified Drug (Edit 66)integerlevel : Nominal
Approval_DateApproval date of HCPCS mappingdate-
T_PackagedCode packaged when T procedure presentintegerlevel : Nominal
Radio_Labeled_ProductRadiolabeled products required for nuclear medicine procedureintegerlevel : Nominal
Nuclear_MedicineNuclear medicine procedure requires diagnostic radiopharmaceuticalintegerlevel : Nominal
Service_Not_Billable_FIService not billable by medicareintegerlevel : Nominal
PHP_Sycho_TherapyPsychotherapy talk therapyintegerlevel : Nominal
All_PHP_ServiceCode applicable for Partial Hospitalization logicintegerlevel : Nominal
Daily_Mental_Health_ServiceCode included in Daily Mental Health services capintegerlevel : Nominal
Red_Blood_CellsRed blood cells (RBCs), also called erythrocytes, are the most common type of blood cell and the vertebrate's principal means of delivering oxygen (O2) to the body tissues—via blood flow through the circulatory systemintegerlevel : Nominal
Whole_Blood_CellsWhole blood is made up of red blood cells, white blood cells, platelets, and blood plasma. ... The blood is typically combined with an anticoagulant and preservative during the collection process.integerlevel : Nominal
Critical_Care_AncillaryCritical care ancillary serviceintegerlevel : Nominal
Deductible_Coinsurance_NADeductible & coinsurance no applicableintegerlevel : Nominal
Coinsurance_NACoinsurance no applicableintegerlevel : Nominal
Skin_Substitute_ProcedureCode included as skin substitute application procedureintegerlevel : Nominal
Skin_SubstituteCode included as skin substitute productintegerlevel : Nominal
Comprehensive_APC_ExclusionNumeric rank for primary comprehensive APC procedureintegerlevel : Nominal
Device_ProcedureCode included as a device-dependent procedure (Edit 92)integerlevel : Nominal
DeviceCode included as a device for a device-dependent procedure (Edit 92)integerlevel : Nominal
Skin_Substitute_Procedure_LowCode included as a low cost skin substitute procedure (Edit 87)integerlevel : Nominal
Skin_Substitute_LowCode included as a low cost skin substitute product (Edit 87)integerlevel : Nominal
Skin_Substitute_Procedure_HighCode included as a high cost skin substitute product (Edit 87)integerlevel : Nominal
Skin_Substitute_HighCode included as a high cost skin substitute product (Edit 87)integerlevel : Nominal
Lab_ServiceCode included as a non-packaged laboratory service for bill type 14Xintegerlevel : Nominal
FQHC_PreventiveCode included as FQHC PPS preventive service for bill type 77Xintegerlevel : Nominal
FQHC_Influenza_PpvCode included as FQHC PPS influenza/PPV vaccine service for bill type 77Xintegerlevel : Nominal
FQHC_NonCoveredCode included as FQHC PPS non-covered service for bill type 77Xintegerlevel : Nominal
FQHC_AddonCode included as FQHC PPS mental health add-on service code requiring primary procedure code for bill type 77Xintegerlevel : Nominal
FQHC_PrimaryCode included as FQHC PPS primary procedure service code to be reported with mental health add-on service code for bill type 77Xintegerlevel : Nominal
Device_Procedure_BypassCode included as a device-dependent procedure (Edit 92)integerlevel : Nominal
SRS_Plan_And_PrepSupplementary retirement scheme planintegerlevel : Nominal
NonStandard_CT_ScanModifier CT lets CMS know you're using non-standard equipment, and reduces your Medicare Part B paymentsintegerlevel : Nominal
Cornea_TransplantCorneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissueintegerlevel : Nominal
Stereotactic_RadiosurgeryStereotactic radiosurgery (SRS) is a non-surgical radiation therapy used to treat functional abnormalities and small tumors of the brainintegerlevel : Nominal
Cornea_Tissue_ProcessingThis code includes tissue recovery, evaluation, medical review and laboratory tests for infectious disease, processing, and transportationintegerlevel : Nominal
Advanced_Care_PlanningAdvance care planning is a process that enables individuals to make plans about their future healthcare.integerlevel : Nominal
Annual_Wellness_VisitMedicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213,integerlevel : Nominal
Terminated_Device_ProcedureTermination device procedure indicates the mid-quarter date when a code or change becomes inactiveintegerlevel : Nominal
Pass_Through_Skin_ProductPass thorough skin product codesintegerlevel : Nominal
Negative_Pressure_Wound_TherapyNegative-pressure wound therapy (NPWT) is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second- and third-degree burnsintegerlevel : Nominal
Film_XRayFilm Xray codeintegerlevel : Nominal
Allogeneic_TransplantAllotransplant is the transplantation of cells, tissues, or organs, to a recipient from a genetically non-identical donor of the same speciesintegerlevel : Nominal
FQHC_Chronic_CareFederally Qualified Health Centers Chronic Care Management (CCM)integerlevel : Nominal
Version_ComparedValid Versions Comparison to the latest Versionintegerlevel : Nominal
Begin_DateEffective date of “VER”date-
TypeHCPCSAmbulatory_Payment_ClassificationStatus_IndicatorPayment_IndicatorGender_CodeMax_Units_AllowedQuestionable_ServiceService_Not_Paid_By_MedicareNot_Recognized_By_MedicareIs_Conditional_BilateralIs_Independent_BilateralInherent_BilateralComprehensiveComponentIs_Activity_TherapyIs_Occupational_TherapyNonCovered_ServiceNot_Included_In_OPPSIs_AddOnVaccineAntigenSplintCastDeductible_NABlood_ServiceBlood_ProductPHP_ServiceDescriptionExclusive_BilateralLab_PathSometimes_TherapyTrauma_RevCode_RequiredCritical_Care_Requires_TraumaSTV_PackagedSeparate_ProcedureStatutory_ExclusionHourly_ObservationDirect_Admit_ObsNot_Recognized_By_OPPSDME_OnlyUnclassified_DrugApproval_DateT_PackagedRadio_Labeled_ProductNuclear_MedicineService_Not_Billable_FIPHP_Sycho_TherapyAll_PHP_ServiceDaily_Mental_Health_ServiceRed_Blood_CellsWhole_Blood_CellsCritical_Care_AncillaryDeductible_Coinsurance_NACoinsurance_NASkin_Substitute_ProcedureSkin_SubstituteComprehensive_APC_ExclusionDevice_ProcedureDeviceSkin_Substitute_Procedure_LowSkin_Substitute_LowSkin_Substitute_Procedure_HighSkin_Substitute_HighLab_ServiceFQHC_PreventiveFQHC_Influenza_PpvFQHC_NonCoveredFQHC_AddonFQHC_PrimaryDevice_Procedure_BypassSRS_Plan_And_PrepNonStandard_CT_ScanCornea_TransplantStereotactic_RadiosurgeryCornea_Tissue_ProcessingAdvanced_Care_PlanningAnnual_Wellness_VisitTerminated_Device_ProcedurePass_Through_Skin_ProductNegative_Pressure_Wound_TherapyFilm_XRayAllogeneic_TransplantFQHC_Chronic_CareVersion_ComparedBegin_Date
ModificationG6015702018-01-01
ModificationG6016702018-01-01
Modification0004U1702018-01-01
Modification0005U1702018-01-01
Modification0006U1702018-01-01
Modification0007U1702018-01-01
Modification0008M0702018-01-01
Modification0008U1702018-01-01
Modification0010U1702018-01-01
Modification0011U1702018-01-01