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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 in this manual, many policies are described using the term "physician". Unless otherwise 
indicated, the use of this term does not restrict the application of policies to physicians only. Rather, the 
policies apply to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT 
codes pursuant to applicable portions of the Social Security Act (SS) of 1965, the Code of Federal Regulations 
(CFR), and Medicare rules. Providers/ suppliers reporting services under Medicare's hospital Outpatient 
Prospective Payment System (OPPS) shall report all services in accordance with appropriate Medicare "IOM" 
instructions. You can find this information in the National Correct Coding Initiative Policy Manual, Chapter 1 - 
General Correct Coding Policies, Section A. Introduction. 
 
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 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 I/OCE in the claim record, 
1=OPPS, 2=Non-OPPS; a blank, zero, or any other value is defaulted to 1. The I/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 I/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 that caused the action. You can find this information in the CMS.gov Outpatient Code 
Editor (OCE). 
 
 
The rules say that if 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 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 date 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 lists and describes each edit disposition. 
 
Disposition Claim Return to Provider (RTP) - 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 - 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. 
 
Payment APC Description - APC used to determine payment. If no APC assigned to line item, the value 00000 
is assigned. For partial hospitalization and some inpatient-only, and other procedure claims, the payment APC 
may be different than the APC assigned to the HCPCS code. 
 
HCPCS APC Description - APC assigned to HCPCS code 
 
Status Indicator Description V - Clinic or emergency department visit 
 
Status Indicator Description J2 - Hospital Part B services that may be paid through a comprehensive APC 
 
You can find this information in Medicare's CMS.gov, I/OCE Quarterly Release File, Integrated OCE (IOCE) 
CMS Specifications V23.1 Effective 04/01/2022; 5.1.2 Multiple Medical Visit Conditions, 5.1.2.1 Multiple 
Medical Visit Conditions Table, 6.1 Introduction to Edits, 6.1.1 Edit Dispositions Table, 6.2 Edit Descriptions 
and Reason for Edit Generation Table, 7.1.2 APC Return Buffer Table. 
 
The rules say HCPCS code G0402 - Initial preventive exam, SI-V, APC -5012 
 
HCPCS code G0463 - Hospital outpatient clinic visit, SI - J2, APC -5012. You can find this information in the 
CMS.gov, Hospital Outpatient PPS, April 2022 Web Addendum B and CMS.gov, Hospital Outpatient PPS, 
April 2022 Web Addendum A. 
 
The rules say section 18331(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; 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 the 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. 
 
Each HCPCS code for which separate payment is made under the OPPS is assigned to an ambulatory payment 
classification (APC) group. The payment rate and coinsurance amount calculated for an APC apply to all of the 
services assigned to the APC. A hospital may receive a number of APC payments for the services furnished to 
a patient on a single day; however, multiple surgical procedures furnished on the same day are subject to 
discounting. (See section 10.5 for discussion of multiple procedure discounting under the OPPS). You can find 
this information in the Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient 
Hospital Part B and OPPS), Section 10.1- Background, 10.1.1- Payment Status Indicators, 10.2 APC Payment 
Groups and 40.1- Integrated OCE (July 2007 and Later), 120.1 Bill Types Subject to OPPS, 180.4 - Proper 
Reporting of Condition Code G0(Zero). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.