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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 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 (SSA) of 1965, the Code of Federal 
Regulations (CFR), and Medicare rules. In some sections of this Manual, the term physician would not 
include some of these entities because specific rules do not apply to them. For example, Anesthesia Rules [e.g., 
CMS "Internet-only Manual (IOM)," Publication 100-04 ("Medicare Claims Processing Manual"), Chapter 12 
(Physician/Nonphysician Practitioners), Section 50(Payment for Anesthesiology Services)] and Global Surgery 
Rules [e.g., CMS "Internet-only Manual (IOM), Publication 100-04 ("Medicare Claims Processing Manual"), 
Chapter 12 (Physician/Nonphysician Practitioners), Section 40 (Surgeons and Global Surgery)] do not apply to 
hospitals. Providers reporting services under Medicares hospital Outpatient Prospective Payment System 
(OPPS) shall report all services in accordance with appropriate Medicare IOM" instructions. You can find this 
guidance in the National Correct Coding Initiative Policy Manual, Chapter 1 General Correct Coding Policies, 
Section A. Introduction. 
 
Medicare guidance says this integrated OCE (IOCE) program processes claims for outpatient institutional 
providers including hospitals that are subject to the Outpatient Prospective Payment System (OPPS) as well as 
hospitals that are not (Non-OPPS). The Medicare Administrative Contractor (MAC) identify the claim as 
OPPS or Non-OPPS by passing a flag to the IOCE in the claim record, 1=OPPS, 2=Non-OPPS; a blank, 
zero, or any other value is defaulted to 1. This version of the IOCE processes claims consisting of single or 
multiple days of service. The IOCE performs two major functions: 
1. Edit the data to identify errors and return a series of edit flags. 
2. Assign an Ambulatory Payment Classification (APC) number for each service covered under OPPS, and 
return information to be used as input to an OPPS PRICER program. For Non-OPPS claims an APC is not 
assigned, instead a series of Non-OPPS applicable edits are returned. The IOCE 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 IOCE 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. If there are multiple 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, 
Integrated OCE (IOCE) CMS Specifications V22.0 effective July 01, 2021, 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. 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. 
 
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 40.1  
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.