Pathology/Lab Coding Alert

CMS has disabled the unit-of-service edit in the Outpatient Code Editor (OCE) until implementation of the new version in October 2002. Edit 15, "service unit out of range for procedure," was causing many denials for claims filed under the Outpatient Prospective Payment System (OPPS). CMS discontinued the edit on May 6, 2002, and providers who have had claims returned due to the edit should resubmit after that date.

"Because the maximum units for each service have not been publicized, coders have had to take a hit-or-miss approach to edit 15, which limits the number of times per day a specific HCPCS Codes can be reported for an individual patient," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the national advisory board of the American Academy of Professional Coders (AAPC) and president of Physician Coding and Compliance Consulting in Manassas, Va. "Although coders have a brief reprieve while the edit is suspended, they must understand appropriate modifier usage to ensure fair payment for multiple units of service once the edit is back online." OCE Edits OPPS Claims OCE is the CMS software package for processing outpatient claims issued to fiscal intermediaries and carriers. "Although OCE has been used for years to identify incorrect billing data for hospital outpatients, it was expanded to play a central role in processing OPPS claims," Castillo says. FIs and carriers use the revised code-editing software to edit outpatient Part A and Part B claims. The software has two main functions: 1) to edit claims data to identify and return a message regarding errors, and 2) to assign an ambulatory payment classification (APC) number for each service covered under OPPS to determine reimbursement. Edit 15 for maximum unit of service is just one of 54 edits in OCE. When one of the edits identifies a reporting discrepancy in the diagnosis, procedure, modifier, date, or units of service, for example, the OCE either 1) rejects or denies the claim or line item, or 2) returns or suspends the claim.

"Claims with a service unit greater than allowable for the procedure are returned to the provider [RTP]," says Castillo. A claim RTP means the provider can resubmit the claim once the problems are corrected, according to CMS. "In other words, you can resubmit the bill using appropriate modifiers to override the edit," Castillo says. CMS Determines Maximum Units of Service According to program memorandum A-02-025, CMS reviewed narrative code descriptions and standards of medical/surgical practice (those used in the development of the national Correct Coding Initiative) to establish the maximum units of service for each HCPCS code. No maximum allowable units of service have been established for "unlisted procedures," because these [...]