This lesson explains the function of the Outpatient Code Editor (OCE), including the National Correct Coding Initiative (NCCI) edits, in the processing of Outpatient Prospective Payment System (OPPS) claims. The lesson will cover Procedure to Procedure (PTP), Medically Unlikely Edits (MUEs), and Add-on Edits within the NCCI edits.
“This program has been approved for 0.50 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
This activity is approved for 0.50 contact hours.
Section 1: Introduction
About This Course
Section 2: Integrated Code Editor
Integrated Outpatient Code Editor Background
Integrated Outpatient Code Editor Software
Section 3: OCE Edits
Current OCE Edits
Current OCE Dispositions
Sample RTP Edits
OCE Edit 17 Associated with the Bilateral Modifier
OCE Edit 74 Associated with the Bilateral Modifier
OCE Edit 21
OCE Edits Associated with Observation Services
Section 4: PTP Edits
OCE Edits and NCCI Edits
Procedure to Procedure (PTP) Edits
Allowable Modifier Designation
Non-modifiable NCCI Edits: OCE Edit 20
Modifiable NCCI Edits: OCE Edit 40
NCCI Coding Policy Manual for Medicare Services
Section 5: Medically Unlikely Edits
Medically Unlikely Edits, Part 2
Adjudication of Medically Unlikely Edits
Examples of Medically Unlikely Edits
Examples of Laboratory Medically Unlikely Edits
Add-on Code Edits
Section 6: Conclusion
Expert Reviewer: Richard R. Cooley, BA, CCS
Jean Russell has over thirty years of healthcare and information system experience. Her areas of expertise include the Medicare outpatient prospective payment systems (APCs, and APGs), as well as ICD-10-CM/PCS training, Charge Description Master (CDM), admission status reviews, and outpatient coding and compliance. She is a frequent speaker at the national, state and local levels for HFMA and AHIMA professional groups. Jean has her Masters from the University of Houston in Biomedical Engineering; her Bachelors from Colgate University in Biology; and her RHIT from the independent study program through the American Health Information Management Association.Disclosure: Jean C. Russell, MS, RHIT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Richard has more than eighteen years in healthcare consulting. He has developed an expertise in hospital outpatient and inpatient coding, including professional split billing and E/M coding, admission criteria, reimbursement and compliance, and charge master reviews. His areas of expertise include Medicare reimbursement for the Medicare Outpatient Prospective Payment System (OPPS), Medicaid Ambulatory Payment Groups (APGs), as well as commercial payers, and professional reimbursement. He is a certified coder with AHIMA (CCS). Richard earned his Bachelors from Hobart College.Disclosure: Richard R. Cooley, BA, CCS has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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