Pathology/Lab Coding Alert

The OCE is the HCFA software package for processing outpatient claims, issued to fiscal intermediaries and carriers. Historically, OCE edited hospital outpatient and physician claims to identify incorrect billing data and to screen CPT and ICD-9 codes for coverage and validity, 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 its northern Virginia chapter. The revised OCE has expanded capabilities and plays a central role in processing claims under the new outpatient prospective payment system (OPPS), Castillo says. The code-editing software is used to edit all outpatient part A claims, and part B claims (except for Indian Health Services, Critical Access, and Maryland Hospitals).

The revised OCE serves two main functions:

1. To edit claims data to identify errors and return edit messages regarding the errors; and

2. To assign an ambulatory payment classification (APC) number for each service covered under OPPS, used to determine reimbursement amounts.

There are several major changes in claims processing under the revised OCE, including:

OCE now requires submission of one claim record for all services involved in the outpatient encounter, even if it spans more than one calendar day;

Revised OCE contains additional editing parameters (such as the maximum unit edits);

The updated OCE returns flags, or messages regarding the action to be taken when an edit identifies improper coding, (e.g., claim rejection, claim return to provider, line item denial, etc.). The edits include Correct Coding Initiative (CCI) edits for CPT code pairs that cannot be reported together, maximum unit edits, and coverage edits linking CPT and ICD-9 codes; and

The new OCE computes information used for payment purposes.