The Integrated Outpatient Code Editor (I/OCE) is software which combines editing logic to process OPPS (outpatient prospective payment) claims and non-OPPS claims such as Ambulatory Surgery Claims. The software performs the following functions when processing a claim:
Edits a claim for accuracy of submitted data
Assigns APCs (Ambulatory Payment Classifications)
Assigns CMS-designated status indicators
Assigns payment indicators
Computes discounts, if applicable
Determines a claim disposition based on generated edits
Determines if packaging is applicable
Determines payment adjustment, if applicable
In addition to its editing function, the I/OCE program screens each procedure code against a list of approximately 2500 ASC procedures and summarizes whether or not the bill is subject to the ASC limitation.
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 (e.g., a specific diagnosis) that caused the action.
In general, the I/OCE performs all functions that require specific reference to HCPCS codes, HCPCS modifiers and ICD-9-CM diagnosis codes. Since these coding systems are complex and regularly updated, having all the codes in a single program reduces system maintenance and the chance of inconsistent processing.
Why is the I/OCE important to health-system pharmacists?
When processing drug claims, if an individual error is identified by the I/OCE, a process review should be undertaken to determine the cause of the billing error for correction. This allows errors to be detected and corrected before the claim is transmitted to the payer. One common error for drug claims is when a Medically Unlikely Edit (MUE) is excited the I/OCE will stop the claim for review. For pharmacists who advise Ambulatory Surgery Centers will find a summary each quarter of whether or not a bill is subject to the ASC limitation.
Each quarter, new I/OCE software is released with a detailed analysis of each edit, when it is applied and potential resolutions. The I/OCE Quarterly Release Files are maintained by CMS at: https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.
Pharmacy, Billers and Revenue Integrity should work together to identify repetitive billing errors for drugs identified by the I/OCE and evaluate potential process changes to prevent the errors from occurring.
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