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Title Details
HCFA Outpatient Code Editor with Ambulatory Payment Classification (OCE/APC) for Medicare Billing
National Technical Information Service
Coding


Outpatient Code Editor (OCE) software was developed to ensure accurate coding by detecting potential problems in the coding of claims data. Diagnoses are coded by ICD-9-CM classification; procedures are coded by HCPCS classification.

PC Software for Windows 95 and 98

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Specifications: Pentium PC, Windows 95 or greater, 50Mb Hard disk space.

Claims can be either batch processed or entered one at a time.

About the Software

Hospitals or other facilities with outpatient billing will find this software an important tool. It combines editing logic with the new Ambulatory Payment Classifications (APC) assignment program designed to meet mandated Medicare outpatient prospective payment system (OPPS) implementation. The software performs the following functions when processing a claim:
Edits a claim for accuracy of the submitted data
(This includes the National Correct Coding Initiative (CCI) edits)
Assigns APCs
Assigns HCFA-designated service indicators
Assigns payment indicators
Computes discounts, if applicable
Determines the disposition of a claim based on generated edits
Determines if packaging is applicable
Determines payment adjustment, if applicable

The software was developed to ensure accurate coding by detecting potential problems in the coding of claims data. It also assigns APC numbers for services. The program indicates what actions to take when an edit occurs, and the reason(s) why the actions are necessary. For example, an edit can cause a line item to be denied payment while still allowing the claim to be processed for payment. In this case, the line item can not be resubmitted but can be appealed.

For claims with service dates spanning more than one day, each claim is represented by a collection of data, consisting of all necessary demographic (header) data, plus all services provided (line items). The user must then organize all of the applicable services into a single claim record and pass them as a unit to the software.

The OCE program screens each procedure code against: a list of approximately 2200 Ambulatory Surgical Center (ASC) procedures; a list of "Out of Scope" procedures; and the entire CPT code list, including all recent releases. A particular edit message is associated with each type of claim problem identified by OCE software. While the software identifies and indicates the nature of the error, it does not correct the error. OCE software also summarizes whether or not the bill is subject to the ASC limitation and which edit conditions apply.

The software indicates what actions to take when an edit occurs, and reason(s) why the actions are necessary. For example, an edit can cause a line item to be denied payment while still allowing the claim to be processed for payment. In addition, ASC payment based on HCPCS codes allows comparison between outpatient and inpatient reasonable cost and customary charges for the same procedures.

Diagnoses are coded by ICD-9-CM classification; procedures are coded by HCFA Common Procedure Coding System (HCPCS) classification.


About the Medicare Outpatient Payment System
This software was developed for the implementation of the Medicare outpatient prospective payment system (OPPS) for outpatient care. The basic unit of payment is an outpatient visit. The visit could represent one or more procedures, a medical evaluation, or ancillary services such as a chest x-ray or lab test.

Each Ambulatory Payment Classifications (APC) has a pre-established prospective payment amount associated with it. Multiple APCs can be assigned to one outpatient record. If a patient has multiple outpatient services during a single visit, the total payment for the visit is computed as the sum of the individual payments for each service.

Certain services (e.g., physical therapy, diagnostic clinical laboratory) are excluded from Medicare's prospective payment system for hospital outpatient departments. These services are exceptions paid under fee schedules and other prospectively determined rates.

Using the Software

Importing Data
The software allows data gathered from other applications to be directly imported so that claims can be generated by the OCE software without being rekeyed. The documentation discusses this further.

Program Input
The following data elements must be included on a patient record to be successfully processed by the program: Type of bill; Time of coverage; Birth date; Sex; Condition codes; HCPCS/CPT code(s) and modifier(s); Service date; Revenue code; Service units; Charge; Medicare provider number (NPI or OSCAR); ICD-9-diagnostic code(s).


HCFA plans on issuing a new version every three months. Each edition contains the latest billing information as authorized by HCFA.

When filing claims in 2000 from:
Aug. 1 to Sept. 30, you should use Version 1.01
Oct. 1 to Dec. 31, you should use Version 1.1


CPT five-digit codes are copyrighted by the American Medical Association (AMA). CPT is a trademark of the American Medical Association. If you wish to reproduce any of the products listed, you must sign an agreement. Contact NTIS for more information.

CD-ROM Individual Issue
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Publisher Catalog Number SUB5451INQPSGL
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Publisher Catalog Number SUB5451INQPSUB
$504.00   
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HCFA Outpatient Code Editor Ambulatory Payment Classification OCEAPC Medicare Billing

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