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. 
 
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. Providers/suppliers reporting services under Medicares 
hospital Outpatient Prospective Payment System (OPPS) shall report all services in accordance with 
appropriate Medicare "Internet-only Manual (IOM)" instructions. You can find this guidance in the National 
Correct Coding Initiative Policy Manual, Chapter I 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. 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, 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 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. Note: Edit 62 is bypassed if the bill type is 
022x or 023x with or without condition code 07., Disposition  RTP. Name  Status Indicator (SI), Description 
 B Non-allowed item or service for OPPS. You can find this guidance on the Medicare web site, CMS.gov, 
Outpatient Code Editor (OCE), OCE Quarterly Release Files, Integrated OCE (IOCE) CMS Specifications 
V23.0 Effective January 01, 2022, Section 3 Introduction to the IOCE, Section 3.1 IOCE Processing, Section 6 
Edit Application within the IOCE, Section 6.1 Introduction to Edits, Section 6.1.1 Edit Disposition Table, 
Section 6.2 Edit Descriptions and Reason for Edit Generation Table and Section 7.1.2 APC Return Buffer 
Table. On the Medicare web site, CMS.gov, Hospital Outpatient PPS, Addendum A and Addendum B Updates, 
the file January 2022 Web Addendum B January 10, 2022, for Addendum B.  Final OPPS Payment by 
HCPCS Code for CY 2022, HCPCS code 80321 is listed with Status Indicator  B. 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. 
 
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. 
 
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. You can find this guidance in the 
Medicare Claims Processing Manual, Chapter 4  Part B Hospital (Including Inpatient Hospital Part B and 
OPPS), Section 10.1  Background, Section 10.1.1  Payment Status Indicators, Section 40.1  Integrated OCE 
(July 2007 and Later) 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.