New HCFA Memos Affect Payment and Denials

Memo A-01-01

A-01-01 adds three new edits to the January 2001 Outpatient Code Editor (OCE) Specification Version V2.0, which brings the total number of edits to 46. Following is a brief summary of the edits.

Edit 44: Observation revenue code on line item with nonobservation HCPCS code. (The disposition is RTP, meaning the claim will be returned to your facility.)

Edit 45: Service not appropriate for type of bill. (This edit is not activated and it is a line-item denial.)

Edit 46: Partial hospitalization condition code 41 not approved for type of bill. (Edit disposition is RTP.)

Review These Edits Before You Bill

Now 26 edits will kick a claim back to your facility. In the program memo, HCFA also states that edit 7 (procedure and age conflict) is not activated. Edit 9 (noncovered service; a line-item denial) is under review; HCFA will provide guidance.

HCFA explains that to apply edit 15 (service out of range for procedure), all line items with the same HCPCS code are added together.

The new B status indicator is for non-allowed item or service for the outpatient prospective payment system (OPPS), bringing the total number of status indicators to 15.

The following codes will not be reimbursed because they are paid under other APCs: G0176 (activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patients disabling mental health problems), G0129 (occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per day) and G0177 (training and educational services related to the care and treatment of patients disabling mental health problems).

The memo includes a chart that explains the rationale for edits 29-36, which pertain to partial hospitalization/mental health claims, and describes circumstances under which claims will be paid, suspended or returned.

Memo A-01-10

The memo contains new long descriptions for 28 C codes, including name-change alerts, additional catheter information and the addition of certain models of defibrillators. It also states that C8100 is no longer eligible for pass-through payment.

You can view these memos at www.hcfa.gov/pubforms/transmit/a0101.pdf and www.hcfa.gov/pubforms/transmit/a0110.pdf.

Note: Youll need Adobe Acrobat to open these files.



- Published on 2001-03-01