Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for codes 36415, 82495, and 83018 billed to the enrollee for date
of service September 12, 2022.

You asked the Plan to pay for this claim as billed. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned
the Plans denial. The Plan requested a reopen and provided additional information. The Plan noted that the
guidelines state if two Outpatient Prospective Payment System (OPPS) claims were billed separately for the
same date of service (DOS) by the same provider, they would need to be run through the claims system
Webstrat together since coding guidelines need to be applied to all outpatient charges together for each DOS.
This concept is supported by the Medicare and Health & Human Services OCE guidelines that advise "It
is the user's responsibility to organize all applicable services into a single claim record". Meaning that
all applicable services need to be processed together so that coding guidelines can be correctly applied to
all outpatient charges together for each DOS. Per the Medicare Outpatient Code Editor (OCE) page:
Each claim will be represented by a collection of data, which will consist of all necessary demographic
(header) data, plus all services provided (line items). It is the user's responsibility to organize all
applicable services into a single claim record and pass them as a unit to the I/OCE. The I/OCE only
functions on a single claim and does not have any crossclaim capabilities.

Per the Outpatient Code Editor (OCE) page on the HHS.gov website: Each claim will be represented by a
collection of data, which will consist of all necessary demographic (header) data, plus all services provided
(line items). It is the user's responsibility to organize all applicable services into a single claim record and pass
them as a unit to the I/OCE. The I/OCE only functions on a single claim and does not have any crossclaim
capabilities. As all applicable services need to be processed together so that APC guidelines can be correctly
applied to all outpatient charges together for each date of service, codes 36415, 82495, and 83018 are not
separately payable from code 73522 that was billed on a separate claim for the same date of service, by the
same provider. Per Medicare Claims Processing Manual Chapter 4, Section 10.4 C 5 - Packaging Types Under
the OPPS: Q4 services are assigned to laboratory HCPCS codes that appear on the Clinical Laboratory Fee
Schedule (CLFS). Status indicator Q4 designates packaged APC payment if billed on the same claim as
a HCPCS code assigned status indicator "J1," "J2," "S," "T," "V," "Q1," "Q2," or "Q3." Per CMS OPPS
Addendum B, April 2022 version: Procedure code 73522 has a status indicator of Q1. Procedure codes 36415,
82495, and 83018 have a status indicator of Q4. As all applicable services need to be processed together (even
if billed on separate claims) so that APC guidelines can be correctly applied to all outpatient charges together
for each date of service, procedure codes 36415, 82495, and 83018 are packaged charges and are not separately
payable.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the Plan has demonstrated that the services billed were not submitted for
payment together as is required by the Medicare guidelines. Therefore, we decided that the Plan does not have
to pay for codes 36415, 82495, and 83018 billed to the enrollee for date of service September 12, 2022.