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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. 
 
Medicare guidance says Section 1833(t) of the Social Security Act (the Act) as amended by Section 4533 of the 
Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare PPS for: *Hospital outpatient 
services, including partial hospitalization services. The CMS incorporates new processing requirements in the 
Outpatient Code Editor (OCE) by releasing a new or updated version of the software each quarter. The OCE 
instructions and specifications are utilized under: 
* The OPPS for hospital outpatient departments, Community Mental Health Centers (CMHCs) and for limited 
services provided in a Home Health Agency (HHA) not under the Home Health Prospective Payment System 
or to a hospice patient for the treatment of a non-terminal illness. 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 I/OCE instructions and specifications are provided via Recurring Update 
Notifications. They are also posted on the Web at the following address: 
http://www.cms.hhs.gov/OutpatientCodeEdit/02_OCEQtrReleaseSpecs.asp#TopOfPage 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. 
Hospitals subject to OPPS report Condition Code G0 on FLs 24-30 (or the corresponding electronic location) 
when multiple medical visits occurred on the same day in the same revenue center but the visits were distinct 
and constituted independent visits. An example of such a situation would be a beneficiary going to the 
emergency room twice on the same day, in the morning for a broken arm and later for chest pain. 
Multiple medical visits on the same day in the same revenue center may be submitted on separate claims. Hospitals should report condition code G0 on the second claim. Appropriate reporting of Condition Code G0 
allows for accurate payment under OPPS in this situation. The OCE contains an edit that will reject multiple 
medical visits on the same day with the same revenue code without the presence of Condition Code G0. You 
can find this guidance in the Medicare Claims Processing Manual, Chapter 4  Part B Hospital (Including 
Inpatient Hospital Part B and OPPS), Section 10 - Hospital Outpatient Prospective Payment System (OPPS), 
Section 10.1  Background, Section 40  Outpatient Code Editor (OCE), Section 40.1  Integrated OCE (July 
2007 and Later), Section 120.1  Bill Types Subject to OPPS and Section 180.4  Proper Reporting of 
Condition Code G0 (Zero). 
 
The rules say that there are multiple evaluation and management (E&M) codes on the same day, on the same 
claim, the rules associated with multiple medical visits are shown in the following table. 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. 
The condition code G0 specifies that multiple medical visits occurred on the same day with the same revenue 
center, and that these visits were distinct and constituted independent visits (e.g., two visits to the ER for chest 
pain, one in the morning and one in the afternoon, and/or two visits to the ER, one in the morning for a 
fractured arm and one later in the day for chest pain).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. 
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. 
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, Disposition  RTP. You can 
find this guidance on the Medicare web site CMS.gov, Outpatient Code Editor (OCE), Integrated OCE (IOCE) 
CMS Specifications V23.2 effective July 01, 2022, Section 3 Introduction to the IOCE, Section 3.1 IOCE 
Processing, Section 5 Processing Conditions Applied to OPPS Claims Only, Section 5.1.2 Multiple Medical 
Visit Conditions, Section 5.1.2.1 Multiple Medical Visit Conditions, Section 6 Edit Application within the 
IOCE, Section 6.1 Introduction to Edits, Section 6.1.1 Edit Dispositions Table and Section 6.2 Edit 
Descriptions and Reason for Edit Generation Table. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.