OPPS Denial – F74, F88, and P60 Revenue Code/HCPCS Issues on Outpatient Rebill

[Chuckrys]

Hello everyone,

I’m working on an outpatient hospital claim (TOB 137) that was downgraded from an inpatient claim and is now denying under OPPS editing for a United Healthcare Community Plan Medicare Dual SNP in New York. The claim is returning the following remark codes:

• F74: Revenue code requires a HCPCS/CPT code
• F88: Code not recognized by Outpatient Prospective Payment System (OPPS); alternate code may be available
• P60: (Remark code returned on claim — related to claim processing/editing issues

We also included:

• Observation hours under G0378
• Emergency department visit 99285 with modifier 25

The claim includes multiple revenue centers (pharmacy, lab, ED, observation, radiology, dialysis, and drug administration) and was rebilled after an inpatient (TOB 111) reversal. Despite attaching HCPCS/CPT codes where applicable, the claim is still denying at the line level. It appears some revenue codes may be missing required HCPCS associations, and certain procedure codes may not be recognized under OPPS. Has anyone experienced these edits when rebilling downgraded inpatient claims to outpatient status? Specifically:

• What is the best way to ensure all revenue codes are properly paired with valid HCPCS/CPT codes under OPPS?
• Are there known issues with certain lab, pharmacy, or observation codes triggering F88 edits?
• Is a full claim rebuild required instead of a corrected claim submission in these cases?

Any guidance on how to resolve these edits and correctly structure the claim for OPPS acceptance would be appreciated.


Thank you.

Sarah C

 

[sls314]

Hello everyone,

I’m working on an outpatient hospital claim (TOB 137) that was downgraded from an inpatient claim and is now denying under OPPS editing for a United Healthcare Community Plan Medicare Dual SNP in New York. The claim is returning the following remark codes:

• F74: Revenue code requires a HCPCS/CPT code
• F88: Code not recognized by Outpatient Prospective Payment System (OPPS); alternate code may be available
• P60: (Remark code returned on claim — related to claim processing/editing issues

We also included:

• Observation hours under G0378
• Emergency department visit 99285 with modifier 25

The claim includes multiple revenue centers (pharmacy, lab, ED, observation, radiology, dialysis, and drug administration) and was rebilled after an inpatient (TOB 111) reversal. Despite attaching HCPCS/CPT codes where applicable, the claim is still denying at the line level. It appears some revenue codes may be missing required HCPCS associations, and certain procedure codes may not be recognized under OPPS. Has anyone experienced these edits when rebilling downgraded inpatient claims to outpatient status? Specifically:

• What is the best way to ensure all revenue codes are properly paired with valid HCPCS/CPT codes under OPPS?
• Are there known issues with certain lab, pharmacy, or observation codes triggering F88 edits?
• Is a full claim rebuild required instead of a corrected claim submission in these cases?

Any guidance on how to resolve these edits and correctly structure the claim for OPPS acceptance would be appreciated.


Thank you.

Sarah C

You can find the OPPS data files on the CMS website. Addendum B lists the mapping for each HCPC/CPT that can be billed under OPPS methodology. That would be a good start for you to review whether you're using any HCPC/CPT that isn't mapped under OPPS methodology.

Here's a link to the CMS site for OPPS. If you look to the side menu, you'll also see links to things like Annual Policy Files and Quarterly Addenda Updates. You can find Addendum B on those side links, as well as a wealth of other information: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient

Side menu:




I'd also suggest looking on your MAC website, because they'll likely have some resources about claims processing and revenue codes. Each MAC has it's own website - some are more user friendly than others to navigate, but they mostly all have the same general information somewhere on the site.