MLN Matters® Number: MM6618
Related Change Request (CR) #: 6618
Related CR Release Date: August 28, 2009
Effective Date: October 1, 2009
Related CR Transmittal #: R1809CP
Implementation Date: October 5, 2009

Provider Types Affected
All providers who submit institutional outpatient claims (including non-outpatient prospective payment system (non-OPPS) hospitals) to Medicare Administrative Contractors (MACs), Fiscal Intermediaries (FIs), or Regional Home Health Intermediaries (RHHIs) for outpatient services provided to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 6618, which notifies providers that the I/OCE Specifications Version 10.3 is effective October 1, 2009. Be sure billing staffs are aware of these changes.

Background
CR 6618 describes changes to billing instructions for various payment policies implemented in the October 2009 OPPS update. The October 2009 Integrated Outpatient Code Editor (I/OCE) changes are also discussed in CR 6618. Attached to CR 6618 are lengthy specifications for the I/OCE. A summary of the changes for October 2009 is within Appendix M of Attachment A of CR 6618 and that summary is captured in the following key points.

Key Points of CR 6618

1. Te program will assign Payment Adjustment Flag #4 (Deductible not applicable) to all lines on any OPPS claim where condition code 'MA' is present on the claim. This modification is effective January 1, 2003. 
   
   
2. Modifier 77 will be added to the list of modifiers that will bypass edit 17 – Inappropriate specification of bilateral procedure. This modification is effective January 1, 2003.
   
   
3. If code G0379 has been denied or rejected it will not be included in any subsequent special direct admission logic. The default SI (Q3) will be retained as the final SI. An exception is if line item adjustment flag (LIAF) = 1 has been assigned to the line, the denial/rejection will be ignored, the line will be included in subsequent direct admission logic and that logic will determine the final SI). This modification is effective January 1, 2008.
   
   
4. STVX/T-packaged codes (Q1, Q2) that are denied or rejected will not be included in any subsequent special packaging logic. The default SI (Q1, Q2) will be retained as the final SI. An exception is if LIAF = 1 has been assigned to the line, the denial/rejection will be ignored, the line will be included in subsequent special packaging logic and that logic will determine the final SI). This modification is effective January 1, 2008.
   
   
5. For codes with SI of S, T, V or X that have been denied or rejected, those codes will be ignored in subsequent special S, T, V, X/T logic for packaging Q1 or Q2 codes. An exception is if LIAF = 1 has been assigned to the line, the denial/rejection will be ignored and the line will be included in subsequent logic for packaging the Q1 or Q2 codes. This modification is effective October 1, 2009.
   
   
6. For Multiple Imaging composite processing, any independently bilateral composite candidate with modifier 50 will count as 2 units in applying the composite criteria. If any composite Ambulatory Payment Classification (APC) is assigned on an independent or conditional bilateral line with modifier 50 the modifier will be ignored in assigning the discount formula. This modification is effective January 1, 2009.
   
   
7. Any T-packaged (Q/Q2) independent or conditional bilateral code with modifier 50 that is paid separately will have the modifier ignored in assigning the discount formula. This modification is effective January 1, 2008.
   
   
8. Any STVX-packaged (Q/Q1) independent or conditional bilateral code with modifier 50 that is paid separately will have the modifier ignored in assigning the discount formula. This modification is effective January 1, 2007.
   
   
9. Medicare has made numerous changes to Diagnosis codes, APCs, HCPCS/CPT codes and modifiers. Those changes can be found in Attachment to CR6618 that is titled 'Preliminary Summary of Data Changes Integrated OCE v 10.3 Effective October 1, 2009'.
   
   
10. Version 15.2 of the National Correct Coding Initiatives will be implemented effective with the October 2009 version of the I/OCE.

Additional Information
If you have any questions, please contact our provider service center at our toll-free number, (877) 567-9249 (for North Carolina and South Carolina Part A providers) or (866) 801-5301 (for home health and hospice providers).

The official instruction (CR6618) issued to your Medicare MAC and/or FI is available at www.cms.hhs.gov/Transmittals/downloads/R1809CP.pdf  (PDF, 3.14 MB) on the CMS Web site.

CMS also has a Web-based training module on the OCE. The module is available at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1 on the Internet.

Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.