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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 OCE will return to the provider any claim that reports a HCPCS code for a device-
intensive procedure that does not also report at least one device HCPCS code required for that procedure. If the 
claim is returned to the provider for failure to pass the edit, the hospital will need to modify the claim by either 
correcting the procedure code or ensuring that one of the required device codes is on the claim before 
resubmission. While all devices that have device HCPCS codes and that were used in a given procedure should 
be reported on the claim, only one of the possible device codes is required to be on the claim for payment to be 
made, unless otherwise specified. 
The device edit does not apply to the specified procedure code if the provider reports one of the following 
modifiers with the procedure code: 
52 - Reduced Services; 
73 - Discontinued outpatient procedure prior to anesthesia administration; and 
74 - Discontinued outpatient procedure after anesthesia administration. 
 
Where a procedure that normally requires a device is interrupted, either before or after the administration of 
anesthesia if anesthesia is required or at any point if anesthesia is not required, and the device is not used, 
hospitals should report modifier 52, 73 or 74 as applicable. The device edit is not applied in these cases. 
The OCE will also return to the provider claims for which specified devices are billed without the procedure 
code that is necessary for the device to have therapeutic benefit to the patient. If the claim is returned to the provider for failure to pass the edit, the hospital will need to modify the claim by either correcting the device 
code or ensuring that one of the required procedure codes is on the claim before resubmission. 
 
The rules say that 
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 non-patient laboratory specimens and is no longer 
applicable for partial hospitalization billing. 
CMHC bills (bill type 76X); 
CORF claims for hepatitis B vaccines (bill type 75X); 
HHA claims for antigens, hepatitis B vaccines, splints and casts (bill type 34X); and 
For splints, casts and antigens when provided to hospice patients for treatment of a non-terminal illness by 
other than a hospital outpatient department. This requires reporting of condition code 07. 
As a result, A/B MACs (A) shall instruct CORFs, HHAs, and other providers to report HCPCS for these 
services, in order to assure payment under this system. Payment will continue to be made for vaccines provide 
to hospice patients by the Medicare A/B MAC (B). The appropriate HCPCS codes are as follows: 
Categories of Services Requiring HCPCS Codes 
Antigens 95144-95149, 95165, 95170, 95180, and 95199 
Vaccines 90657-90659, 90732, 90744, 90746, 90747, 90748, G0008, G0009, and G0010 
Splints 29105-29131, 29505-29515 
Casts 29000-29085, 29305, 29325-29445, 29450, 29700-29750, 29799 
NOTE: A/B MACs (HHH) shall advise their HHAs to report the above HCPCS codes with the exception of 
vaccines under Revenue Code 0550 (Skilled Nursing). The only time revenue code 0550 may be reported is 
when the HHA is billing for antigens, splints, or casts. See Chapter 18 for the reporting of vaccines by HCPCS 
codes. 
You can find these rules in the Medicare Claims Processing Manual, Chapter 4  Part B Hospital, 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 61.2  Edits for Claims on 
Which Specified Procedures are to be Reported With Device and Section 120.1  Bill Types Subject to OPPS. 
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.