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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the 'integrated' Outpatient Code Editor (I/OCE) program processes claims for all outpatient 
institutional providers including hospitals that are subject to the Outpatient Prospective Payment System 
(OPPS) as well as hospitals that are NOT (Non-OPPS). Claim will be identified as 'OPPS' or 'Non-OPPS' by 
passing a flag to the OCE in the claim record, 1=OPPS, 2= Non-OPPS; a blank, zero, or any other value is 
defaulted to 1. The OCE not only identifies individual errors but also indicates what actions should be taken 
and the reasons why these actions are necessary. In order to accommodate this functionality, the OCE is 
structured to return lists of edit numbers. This structure facilitates the linkage between the actions being taken, 
the reasons for the actions and the information on the claim (e.g., a specific diagnosis) that caused the action. 
CMS.Gov, Integrated OCE (IOCE) CMS Specifications V22.3, Effective 10/01/2021: 5.1.2 Multiple Medical 
Visit Conditions - If there are multiple E&M codes on the same day, on the same claim, the rules associated 
with multiple medical visits are shown in the following table. 5.1.2.1 Multiple Medical Visit Conditions - E & 
M Code  2 or more, Revenue Center - Two or more E&M codes have the same revenue center OR One or 
more E&M codes with units greater than one had same revenue center, Condition Code  Not G0, Action - 
Assign medical APC to each line item with E&M code and Return Claim to Provider, Edit  42. 6.1 
Introduction to Edits - As specified in the introduction to the IOCE, one of the three major functions provided 
by the IOCE is the application of edit(s) to identify errors. Each edit is unique, as it directly links the reason the 
edit is returned, any related information at the line or claim level, and the action required indicated by the edit 
disposition. For example, an edit can cause a line-item rejection or return the claim to the provider. It is 
possible for a claim to have one or more edits in all 6 dispositions. The table below lists and describes each edit 
disposition. 6.1.1 Edit Dispositions Table Disposition  Claim Return to Provider (RTP), Description  There are one or 
more edits present that cause the whole claim to be returned to the provider. A claim returned to the provider 
means that the provider can resubmit the claim once the problems are corrected. 6.2 Edit Descriptions and 
Reason for Edit Generation Table - Edit  42, Edit Description Multiple medical visits on same day with same 
revenue code without condition code G0; Reason for Edit Generation  Multiple medical visits (based on units 
and/or lines) are present on the same day with the same revenue code, without condition code G0 to indicate 
that the visits were distinct and independent of each other. See Medical Visit Processing for more information. 
You can find this information in the Medicare website, CMS.Gov, Outpatient Code Editor (OCE). 
 
The rules say that effective for claims with dates of service July 1, 2007, and after, the non-Outpatient 
Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE. 
This integration will result in the routing of all institutional outpatient claims, including non-OPPS hospital 
claims, through a single integrated OCE eliminating the need to update two separate OCE software packages 
on a quarterly basis. The integrated OCE does not change the current logic that is applied to outpatient bill 
types that already pass through the OPPS OCE software. It merely expands the software usage to include non-
OPPS hospitals. This new software product will be referred to as the Integrated OCE (I/OCE). The following 
bill types are subject to OPPS: All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 
14X and 13X without condition code 41) with the exception of bills from hospitals in Maryland, Indian Health 
Service, CAHs, hospitals located in Saipan, American Samoa, the Virgin Islands and Guam; and hospitals that 
provide Part B only services to their inpatients. Effective 4/1/06 the 14X type of bill is for nonpatient 
laboratory specimens and is no longer applicable for partial hospitalization billing. You can find this 
information in the Medicare Claims Processing Manual Chapter 4 - Part B Hospital (Including Inpatient 
Hospital Part B and OPPS), 40.1 -Integrated OCE (July 2007 and Later) and 120.1 - Bill Types Subject to 
OPPS. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.