Essential tool to ensure that your facility is coding OPPS claims correctly
NTIS is CMS's authorized distributor of the Hospital OPPS National Correct Coding Products
Hospital OPPS CCI ASCII Raw Data Files
SUB-5480
Hospital OPPS CCI Manual on searchable CD-ROM
SUB-5479
Hospital OPPS CCI Manual
SUB-5407
Outpatient Code Editor Plus (OCE+)
SUB-5489
CPT® codes only are copyrighted 2007 by the American Medical Association (AMA). All Rights Reserved. If you wish to reproduce any of the products listed, you must sign an agreement, or call 703-605-6510 for more information.
About the Products
What is the difference between the Outpatient Code Editor edits and the CCI edits?
The OCE edits and the CCI edits are two editing systems used to process fiscal intermediary (hospital outpatient) and carrier-related claims, respectively. The CCI edits are developed based on coding conventions defined in the AMA's CPT Manual, current standards of medical and surgical coding practice, input from specialty societies, and based on analysis of current coding practice. The CCI edits are used for carrier processing of physician services under the Medicare Physician Fee Schedule while the OCE edits are used by intermediaries for processing hospital outpatient services under the Hospital OPPS.
The OCE is used in processing OPPS claims. Within the OCE are over 50 OCE edits, which determine whether a specific code is payable under the hospital OPPS. Many of the CCI edits are included in the OCE edits (see edit #19, 20, 39, and 40 below). The OCE edits are used exclusively under the hospital OPPS - they are not used within the Medicare Physician Fee Schedule.
The CCI edits always consist of pairs of HCPCS codes, and are arranged in two tables. One is the column 1/column 2 correct coding edits table, and the other is known as the mutually exclusive edits table. The OCE edits are arranged in numerical order with descriptions for each edit, as well as a claim disposition for each edit. Examples of OCE edits are listed below. For further information on the latest OCE edits within the hospital OPPS, please visit the CMS Web site at http://cms.hhs.gov/manuals/memos/comm_date_dsc.asp to find the latest transmittal (program memorandum) on the OCE.
Edit
Description
Disposition
1
Invalid diagnosis code
Return to Provider (RTP)
2
Diagnosis and age conflict
RTP
3
Diagnosis and sex conflict
4
Medicare secondary payer alert
Suspend
19
Mutually exclusive procedure that is not allowed by CCI even if appropriate modifier is present
Line Item Rejection
20
Component of a comprehensive procedure that is not allowed by CCI even if appropriate modifier is present
39
Mutually exclusive procedure that would be allowed by CCI if appropriate modifier were present
40
Component of a comprehensive procedure that would be allowed by CCI if appropriate modifier were present
Background information about Hospital Outpatient Prospective Payment System
Section 4523 of the Balanced Budget Act of 1997 (BBA) provides authority for CMS to implement a prospective payment system (PPS) under Medicare for hospital outpatient services, certain Part B services furnished to hospital inpatients who have no Part A coverage, and partial hospitalization services furnished by community mental health centers. The provisions of this section were further modified by sections 201 and 202 of the Balanced Budget Refinement Act of 1999 (BBRA).
All services paid under the new PPS are classified into groups called Ambulatory Payment Classifications or APCs. Services in each APC are similar clinically and in terms of the resources they require. A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC for an encounter.
Section 4523 of the BBA also changed the way beneficiary coinsurance is determined for the services included under the PPS. A coinsurance amount will initially be calculated for each APC based on 20 percent of the national median charge for services in the APC. The coinsurance amount for an APC will not change until such time as the amount becomes 20 percent of the total APC payment. In addition, Section 204 of the BBRA provides that no coinsurance amount can be greater than the hospital inpatient deductible in a given year.
Both the total APC payment and the portion paid as coinsurance amounts will be adjusted to reflect geographic wage variations using the hospital wage index and assuming that the portion of the payment/coinsurance that is attributable to labor is 60 percent.
CMS's final rule for the new system was published in the Federal Register on April 7, 2000 (65 FR 18434). The new system went into effect on August 1, 2000.
What is the Current Issue? CMS issues a new version every three months. Each edition contains the latest billing information as authorized by CMS.