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 0.5000 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 0.5000 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 1
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: Alison Kazmierczak
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 no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
Alison has twenty-nine years of healthcare and information system experience, eleven of those years consulting at hospitals across the United States. Her areas of expertise include all aspects of Soarian Financials Revenue Management including Service Catalog (CDM), Service Maps, CRDT, General Ledger, Contracts, Claims, Reports, and all Master Files. Alison has provided analysis and reconfiguration for optimization, new build services, legacy support for hospital systems moving to a new platform, and training.Disclosure: Alison Kazmierczak has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.
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