Appeal type: unknown
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 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 
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 4, Section 40.1. 
 
The rules say that some codes, known as information only service(s) are subject to edit 112. The reported 
line item is a non-covered service as it is for informational reporting purposes only. Any Healthcare Common 
Procedure Coding System (HCPCS) identified as being an information only service is assigned a non-covered 
status indicator and is line item rejected with no impact on payment. The disposition for this edit is Line Item 
Rejection (LIR) which means that the individual line item is rejected for payment. This line item can be 
corrected and resubmitted, but it cannot be appealed.  
 
Under some circumstances, medical visits on the same date as a procedure result in additional payments. 
Modifier 25 reported with an Evaluation and Management (E&M) code, status indicator V, is used to report a 
medical visit that takes place on the same date that a procedure with status indicator S or T is performed, but 
that is significant and separately identifiable from the procedure. However, if any E&M code that occurs on a 
day with a type T or S procedure does not have a modifier of 25, then edit 21 applies and the claim is 
returned to the provider. You can find this information in the Integrated OCE Centers for Medicare and 
Medicaid Services (CMS) Specifications V23.1 Effective April 1, 2022. 
 
 The rules state that code G0463 (hospital outpatient clinic visit for assessment and management of a patient) 
has an Outpatient Prospective Payment System (OPPS) Status Indicator of "V," indicating that this code is an 
Evaluation and Management code used to report a medical visit that takes place on the same date that a 
procedure with status indicator S or T is performed, but that is significant and separately identifiable from the 
procedure. You can find this rule in the 2021 OPPS Addendum. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.