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APRIL OPPS OUTPATIENT CODE EDITOR (OCE)
Effective April 1st, Version 11.0 of the Correct Coding Initiative edits will be implemented. The OCE for hospitals is always one quarter behind the physician edits. As claims are reviewed by the OCE in your facility, be sure the edits are applied according to the date of service.
DIAGNOSIS FOR OBSERVATION SERVICES
Separately payable observation services (APC 0339) is identified on the claim with HCPCS code G0244 (observation care provided by a facility to a patient with CHF, chest pain or asthma, minimum 8 hours).
The ICD-9-CM diagnosis codes for each of the 3 diagnoses are:
Required
Diagnosis For: |
Eligible
ICD-9-CM
Code |
Code Descriptor |
| Chest Pain |
411.0 |
Post myocardial infarction syndrome |
| 411.1 |
Intermediate coronary syndrome |
| 411.81 |
Coronary occlusion without myocardial infarction |
| 411.89 |
Other acute ischemic heart disease |
| 413.0 |
Angina decubitus |
| 413.1 |
Prinzmetal angina |
| 413.9 |
Other and unspecified angina pectoris |
| 786.05 |
Shortness of breath |
| 786.50 |
Chest pain, unspecified |
| 786.51 |
Precordial pain |
| 786.52 |
Painful respiration |
| 786.59 |
Other chest pain |
| Asthma |
493.01 |
Extrinsic asthma with status asthmaticus |
| 493.02 |
Extrinsic asthma with acute exacerbation |
| 493.11 |
Intrinsic asthma with status asthmaticus |
| 493.12 |
Intrinsic asthma with acute exacerbation |
| 493.21 |
Chronic obstructive asthma with status asthmaticus |
| 493.22 |
Chronic obstructive asthma with acute exacerbation |
| 493.91 |
Asthma, unspecified with status asthmaticus |
| 493.92 |
Asthma, unspecified with acute exacerbation |
| Heart Failure |
391.8 |
Other acute rheumatic heart disease |
| 398.91 |
Rheumatic heart failure (congestive) |
| 402.01 |
Malignant hypertensive heart disease with congestive heart failure |
| 402.11 |
Benign hypertensive heart disease with congestive heart failure |
| 402.91 |
Unspecified hypertensive heart disease with congestive heart failure |
| 404.01 |
Malignant hypertensive heart and renal disease with congestive heart failure |
| 404.03 |
Malignant hypertensive heart and renal disease with congestive heart and renal failure |
| 404.11 |
Benign hypertensive heart and renal disease with congestive heart failure |
| 404.13 |
Benign hypertensive heart and renal disease with congestive heart and renal failure |
| 404.91 |
Unspecified hypertensive heart and renal disease with congestive heart failure |
| 404.93 |
Unspecified hypertensive heart and renal disease with congestive heart and renal failure |
| 428.0 |
Congestive heart failure |
| 428.1 |
Left heart failure |
| 428.20 |
Unspecified systolic heart failure |
| 428.21 |
Acute systolic heart failure |
| 428.22 |
Chronic systolic heart failure |
| 428.23 |
Acute on chronic systolic heart failure |
| 428.30 |
Unspecified diastolic heart failure |
| 428.31 |
Acute diastolic heart failure |
| 428.32 |
Chronic diastolic heart failure |
| 428.33 |
Acute on chronic diastolic heart failure |
| 428.40 |
Unspecified combined systolic and diastolic heart failure |
| 428.41 |
Acute combined systolic and diastolic heart failure |
| 428.42 |
Chronic combined systolic and diastolic heart failure |
| 428.43 |
Acute on chronic combined systolic and diastolic heart failure |
| 428.9 |
Heart failure, unspecified |
Effective April 1st, hospitals must report a qualifying ICD-9-CM diagnosis code in FL 76 (Reason for Visit) or FL 67 (Principal Diagnosis) to receive payment for APC 0339.
MODIFIER -CA
The presence of modifier -CA on the procedure line indicates that an inpatient only procedure was performed on a patient classified as outpatient status. The -CA modifier indicates that an inpatient only procedure was performed on an emergency basis on a patient who expired before being registered to inpatient status.
Effective April 1st, if modifier -CA is submitted on a claim for a patient who did not expire, (patient status code 20), the claim is returned to the provider. A claim returned to the provider means that the provider can resubmit the claim once the problems are corrected.
Edit code 70 (-CA modifier requires patient status code 20) has been added to the outpatient claim editor effective April 1, 2005.
PROCEDURE/DEVICE CODES
Effective for services after January 1, 2005 device category codes were re-instituted. CMS believed that the coding of devices was essential if they were to improve the accuracy of claims data and be able to better calculate the relative costs of device-dependent APCs in relation to other services paid under
OPPS.
Effective April 1st, edit 71 (claim lacks required device code) will be implemented. In the case when certain procedures are performed (and listed on the claim by CPT code) and where certain devices would be used with these procedures, if the device category is not listed on the claim, the claim will be returned to the provider. The provider will have the opportunity to resubmit the claim once the problem is corrected.
These edits will not apply to claims that contain a procedure code reported with modifier -52, -73 or -74. CMS recognizes that in cases where a modifier is listed the procedure might have been interrupted before the device was implanted.
DIABETES SCREENING TESTS
Medicare coverage for diabetes began January 1, 2005. Initially coverage was provided for two screening tests per calendar year. Change Request 3677 and Medlearn Matters Number MM3677 clarify this screening to indicate that for individuals diagnosed with pre-diabetes the two screening tests per year are further limited to one screening test every 6 months. The tests (CPT codes 82947, 82950 or 82951) for individuals with a pre-diabetes diagnosis should be billed with a diagnosis code of V77.1 (special screening for diabetes mellitus) and a TS modifier to reflect the follow up services.
Pre-diabetes is defined as any individual with one of the following risk factors for diabetes:
- Hypertension
- Dyslipidemia
- Obesity (with a body mass index greater than or equal to 30 kg/m2), or
- Previous identification of elevated impaired fasting glucose or glucose intolerance.
Or individuals with any two (2) of the following risk factors is also eligible for this benefit:
- Overweight (a body mass index >25, but < 30 kg/m2)
- A family history of diabetes
- Age 65 years or older
- A history of gestational diabetes mellitus or giving birth to a baby weighing > 9 lbs.
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