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Decision: unknown

 
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 in this Manual many policies are described utilizing the term physician. Unless indicated 
differently the usage of this term does not restrict the policies to physicians only but applies to all practitioners, 
hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT codes pursuant to applicable portions 
of the Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR), and Medicare rules. 
Providers reporting services under Medicares hospital outpatient prospective payment system (OPPS) shall 
report all services in accordance with appropriate Medicare Internet-only Manual (IOM) instructions. 
Procedures shall be reported with the most comprehensive CPT code that describes the services performed. 
 
Outpatient Code Editor (OCE) 
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 
OCE Quarterly Release Files Integrated OCE (IOCE) CMS Specifications V23.0 Effective January 01, 2022 
6 Edit Application within the IOCE 
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 Disposition Table 
Disposition  Claim Return to Provider, 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 62, Edit Description  Code not recognized by OPPS; alternate code for same service may be available, 
Reason for Edit Generation  The procedure code has a Not recognized by Medicare for OPPS indicator. 
Services with a status indicator of B always return edit 62, Disposition  RTP 
7.1.2 APC Return Buffer Table 
Name  Status Indicator (SI), Description  B Non-allowed item or service for OPPS. 
 
10.1.1  Payment Status Indicators 
An OPPS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether 
the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made 
separately or packaged. The status indicator may also provide additional information about how the code is 
paid under the OPPS or under another payment system or fee schedule. For example, services with status 
indicator A are paid under a fee schedule or payment system other than the OPPS. Services with status 
indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. 
Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction 
applies when two or more services with a status indicator of T are billed on the same date of service. 
The full list of status indicators and their definitions is published in Addendum D1 of the OPPS/ASC proposed 
and final rules each year. The status indicator for each HCPCS code is shown in OPPS Addendum B. 
40.1  Integrated OCE (July 2007 and Later) 
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. 
120.1  Bill Types Subject to OPPS 
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. 
CMS.gov 
Hospital Outpatient PPS Addendum A and Addendum B Updates 2022 January Web Addendum B Corrected 
January 10, 2022 Addendum B.  HCPCS code 99215- Office o/p est. hi 40-54 min, Status Indicator  B 
 
You can find this information in the Medicare Claims Processing Manual Chapter 4  Part B Hospital 
(Including Inpatient Hospital Part B and OPPS) 10  Hospital Outpatient Prospective Payment System (OPPS) 
10.1  Background Section 1833(t) of the Social Security Act (the Act) as amended by 4533 of the Balanced 
Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare PPS for: Hospital outpatient services. 
including partial hospitalization services. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.