Integrated Outpatient Code Editor: An Underused Resource

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The Integrated Outpatient Code Editor (I/OCE) program processes claims for all hospital outpatient provider-based departments (PBDs) that are paid according to the Outpatient Prospective Payment System (OPPS). This program edits the data on the claims to identify individual errors (specific to Healthcare Common Procedure Coding System [HCPCS] codes, HCPCS modifiers, and ICD-10-CM diagnosis codes) and indicates actions that should be taken, as well as the reasons certain actions are necessary. The I/OCE also assigns an Ambulatory Payment Classification (APC) number for each service that is covered under OPPS. The I/OCE specifications are one of the most valuable Medicare resources for PBDs and revenue cycle teams because the specifications explain the edits applied to the PBDs’ Part B claims. The Centers for Medicare & Medicaid Services (CMS) also publishes data files with the I/OCE specifications. These data files contain codes for each edit or logic function performed by the I/OCE program. The I/OCE specifications and data files are updated quarterly and are typically published the first week of the month prior to the beginning of a new quarter.¹ Although this large file contains more information than most PBD revenue cycle personnel wish to know, the files are a great library for researching how CMS software makes edits of PBD claims. The following are the I/OCE specification files that this author reviews each quarter: 

FINAL SUMMARY OF DATA CHANGES 

This file is labeled as FinalSumofDataChngsSpecCMS.report and is particularly helpful for PBD program directors and Charge Description Master (CDM) directors because it contains lists of new, revised, and deleted codes, modifiers, revenue codes, and APC group codes. The following are examples of new I/OCE edit information pertinent to wound management that published in this file throughout 2018. (Note that these lists are not inclusive of all the published I/OCE data changes. Readers should view each quarter’s file for the complete list of data changes.) 

ADDED HCPCS CODES: 

January: Q4176 Neopatch, per sq cm 

Q4177 Floweramnioflo, 0.1 cc 

Q4178 Floweramniopatch, per sq cm 

Q4179 Flowerderm, per sq cm 

Q4180 Revita, per sq cm 

Q4181 Amnio wound, per sq cm 

Q4182 Transcyte, per sq cm 

DELETED CURRENT PROCEDURAL TERMINOLOGY CODES: 

January: 29582 Apply multlay comprs upr leg 

29583 Apply multlay comprs upr arm 

HCPCS DESCRIPTION CHANGES: 

               HCPCS        Old Description                      New Description 

January:    17250        Chemical cautery tissue          Chem caut of tissue granltj tissue 

                  Q4132       Grafix core                              Grafix core, grafixpl core 

                  Q4133       Grafix prime                            Grafix prime, grafix pl prime 

                  Q4148       Neox 1k, 1 cm                        Neox, neox rt, or clarix cord 

                  Q4156      Neox 100, 1 sq cm                  Neox 100 or clarix 100 

                  Q4162      Amnio bio and woundex flow  Wndex flw, bioskin flw, 0.5cc 

                  Q4163 Amnio bio and woundex sq cm   Woundex, bioskin, per sq cm

APC CHANGES: 

                              HCPCS          Code Description                    Old APC           New APC 

 January:               15130             Derm autograft trnk/arm/leg     05055                05054 

                              15150             Cult skin grft t/arm/leg              05055                05054

                              15200             Skin full graft trunk                   05055                05054 

                              Q4172            Puraply or puraply am             01657                 00000 

October:                Q4172            Puraply or puraply am             00000                 09082 

STATUS INDICATOR (SI) CHANGES: 

                              HCPCS         Code Description           Old SI             New SI 

January:                Q4172           Puraply or puraply am        G                       N 

October:                Q4172          Puraply or puraply am         N                       G 

PASS-THROUGH DRUG OR BIOLOGICAL OFFSET PROCEDURE CHANGES: 

January: The following pass-through skin substitute product code subject to APC payment offset was removed effective Jan. 1, 2018: Q4172 

October: The following pass-through skin substitute product code subject to APC payment offset was added effective Oct.1, 2018: Q4172 

SKIN SUBSTITUTE LOW-COST PRODUCT PROCEDURE CHANGES: 

January: The following codes were added to the skin substitute low-cost product list effective Jan.1, 2018: Q4176, Q4178, Q4179, Q4180, Q4181, Q4182 

The following code was removed from the skin substitute low-cost product list effective Jan. 1, 2018: Q4162 

April: The following code was removed from the skin substitute low-cost product list effective April 1, 2018: Q4180 

July: The following code was removed from the skin substitute low-cost product list effective July 1, 2018: Q4178 

October: The following code was removed from the skin substitute low-cost product list effective Oct. 1, 2018: Q4181 

SKIN SUBSTITUTE HIGH-COST PRODUCT PROCEDURE CHANGES: 

April: The following code was added to the skin substitute high-cost product list effective April 1, 2018: Q4180 

July: The following code was added to the skin substitute high-cost product list effective April 1, 2018: Q4178 

October: The following code was added to the skin substitute high-cost product list effective Oct. 1, 2018: Q4181 

DELETED DIAGNOSIS CODES: 

October: The following ICD-10 diagnosis codes were deleted from the I/OCE effective 10/1/18: 

T814XXA Infection following a procedure, initial encounter 

T814XXD Infection following a procedure, subsequent encounter 

T814XXS Infection following a procedure, sequela 

1. The “I/OCE Specifications” file labeled IntegOCEspecsV [version number] is where the explanations of the claim edits are found. 

2. The “Summary of Quarterly Release Modifications” is a table in Section 2 of the “I/OCE Specifications,” which details all changes for that quarter. 

3. The file labeled HcpcsMap includes all HCPCS codes and whether they are included in various edits. The first quarter 2019 I/OCE file should be posted on the CMS website at this time. This author is encouraging PBD program directors, CDM directors, and other members of the PBD revenue cycle team to review the valuable information that is contained in the January 2019 update. In addition to providing information needed for updating the CDM, the information found in the I/OCE specifications is helpful when resolving billing and coding issues, researching why claims are stalled or denied, and questioning how codes on a claim will process for payment, denial, rejection, or be returned for correction. Readers should also mark their calendars to review the I/OCE updates each quarter. For notifications of when the I/OCE specifications are released and other pertinent CMS updates, consider registering to receive CMS updates.² n 

Kathleen D. Schaum oversees her own consulting business and is a founding member of the TWC editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net 

1. OCE quarterly release files. CMS. 2018. Accessed online: www.cms.gov/ medicare/coding/outpatientcodeedit/oceqtrreleasespecs.html 

2. MLN matters® articles. CMS. 2018. Accessed online: www.cms. gov/outreach-and-education/medicare-learning-network-mln/ mlnmattersarticles/index.html