Non-OPPS OCE (Rejected Items and Processing Requirements

40.3 - Non-OPPS OCE (Rejected Items and Processing Requirements Prior to 7/1/07 (Rev. 1107, Issued: 11-09-06, Effective: 07-01-07, Implementation: 07-02-07) The following error types will be rejected or returned to the provider for development. (Numbers correspond to the Non -OPPS OCE documentation.) 1. Invalid Diagnosis or Procedure Code The OCE checks each diagnosis code against a table of valid ICD-9-CM diagnosis codes and each procedure code against a table of valid HCPCS codes. If the reported code is not in these tables, the code is considered invalid. For a list of all valid ICD-9-CM codes see “International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Volume I (Diseases),” The CMS approved ICD-9-CM addenda, and new codes are furnished by the A/B MAC (A) for each hospital. For a list of valid HCPCS codes see “Physicians’ Healthcare Current Procedural Terminology, 4th Edition, CPT” and “CMS Healthcare Common Procedure Coding System (HCPCS).” Providers should review the medical record and/or fact sheet and enter the correct diagnosis and procedure codes before returning the bill. 2. Invalid Fourth or Fifth Digit for Diagnosis Codes The OCE identifies any diagnosis code that requires a fourth or fifth digit that is either missing or not valid for the code in question. For a list of all valid fourth and fifth digit ICD-9-CM codes see “International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Volume I (Diseases),” CMS approved ICD-9-CM addenda, and new codes furnished by the A/B MAC (A). Providers should review the medical record and/or fact sheet and enter the correct diagnosis before returning the bill. 3. E-Code as Principal Diagnosis E codes describe the circumstances that caused an injury, not the nature of the injury, and therefore, are not used as a principal diagnosis. E-codes are all ICD-9-CM diagnosis codes that begin with the letter E. For a list of all E-codes, see “International Classification of Disease, 9th Revision, Clinical Modification (ICD-9- CM), Volume I (Diseases).” Providers should review the medical record and/or fact sheet and enter the correct diagnosis before returning the bill. 4. Age Conflict The OCE detects inconsistencies between a patient’s age and any diagnosis on the patient’s record. 5. Sex Conflict The OCE detects inconsistencies between a patient’s sex and a diagnosis or procedure on the patient’s bill. 6. Questionable Covered Procedures These are procedures that may be covered, depending upon the medical circumstances. For example, HCPCS code 19360 “Breast reconstruction with muscle or myocutaneous flap” is a condition that is not covered when performed for cosmetic purposes. However, if this procedure is performed as a follow-up to a radical mastectomy, it is covered. 7. Noncovered Procedures These are procedures that are not payable. The A/B MAC (A) denies the bill. 8. Medicare as Secondary Payer - MSP Alert (versions V1.0 and V1.1 only) Diagnoses codes that identify situations that may involve automobile medical, no- fault or liability insurance. The provider must determine the availability of other insurance coverage before billing Medicare. 9. Invalid Age If the age reported is not between 0 years and 124 years, the OCE assumes the age is in error. If the beneficiary’s age is established at over 124, enter with 123. 10. Invalid Sex The sex code reported must be either 1 (male) or 2 (female). Usually, the A/B MAC (A) can resolve the issue. 11. Date Range This edit is used in internal A/B MAC (A) operations. 12. Valid Date The OCE checks the month, day, and year from FL 6 (from date). If the date is impossible, the A/B MAC (A) returns the bill. 13. Unlisted Procedures These are codes for surgical procedures (i.e., codes generally ending in 99).