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Outpatient Code Editor (OCE) Edits
Description
The Outpatient Code Editor (OCE) is an editing system created and maintained by CMS to process outpatient facility claims. The OCE edits identify incorrect and inappropriate coding of these claims.
The National Correct Coding Initiative (NCCI or CCI) was developed by CMS to promote consistent and correct coding methodologies. NCCI rules look for code pairs that should not be billed together on the same date for the same patient. The hospital procedure-to-procedure (PTP) code pairs operate the same as the practitioner PTP code pairs; however, modifiers and coding pairs may differ because of differences between facility and professional services. Applicable NCCI edits are incorporated into the OCE.
Policy
Blue Cross NC will reimburse services identified through the OCE editing system as billing/coding errors according to the criteria outlined in this policy.
Reimbursement Guidelines
Blue Cross Blue Shield North Carolina (Blue Cross NC) has adopted OCE edits and will use these in processing outpatient facility claims.
Sample of OCE Edits (not all inclusive)
| Edit | Generated when: |
|---|---|
| Invalid diagnosis code | The principal diagnosis field is blank, or the entered diagnosis code is not valid |
| Diagnosis and age conflict | The diagnosis code includes an age range, and the age is outside this range. |
| Invalid procedure code | The entered HCPCS/CPT® code is not valid. |
| Code two of a code pair that is not allowed by NCCI unless an appropriate modifier is appended to code pair | The procedure is of the column two code in a pair of procedures denoted with a modifier indicator of “1”, meaning an appropriate modifier may be allowed to append the code pair and bypass the edit. However, where the medical documentation does not support the use of the modifier on the code pair, the edit will be enforced, and Code two of the code pair will be rejected. |
| Code two of a code pair that is not allowed by NCCI even if appropriate modifier is present | The procedure is the column two code in a pair of procedures, denoted with a modifier indicator of “0”, meaning no modifier may be allowed to append the code pair and bypass the edit. There are no circumstances in which both procedures of the code should be paid for the same member on the same day by the same provider. |
| Invalid modifier | Modifier is not valid. |
| Invalid date | The From, Through, or Service date is invalid, or the service date falls outside the range of the From and Through dates. |
| Invalid age | The age is non-numeric or outside the range of 0-124 years. |
Blue Cross NC will follow NCCI edits as developed by CMS. The column two code is incidental to the column one code and not eligible for separate reimbursement. See separate reimbursement policy “NCCI.”
Rationale
Blue Cross NC reserves the right to implement service edits to apply correct coding guidelines for CPT®, HCPCS, and ICD-10 diagnosis and procedure codes. Service edits are in place to enforce and assist in a consistent claim review process.
National Correct Coding Initiative (NCCI) edits are available at:
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
OCE edits are available at:
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit
References
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html
How to Use the Medicare National Correct Coding Initiative (NCCI) Tools. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/How-to-Use-NCCI-Tools.pdf
Healthcare Common Procedure Coding System
American Medical Association, Current Procedural Terminology (CPT®)
Centers for Disease Control and Prevention, International Classification of Diseases, 10th Revision
History
6/1/2022 - New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)
12/31/2022 - Routine Policy Review. Minor revisions only. (cjw)
Application
These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.
This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this policy.
Disclosures:
Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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