CMS Manual System

1 CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 11149 Date: December 10, 2021 Change Request 12533 SUBJECT: January 2022 Integrated Outpatient code Editor (I/OCE) Specifications Version I. SUMMARY OF CHANGES: This notification provides the Integrated OCE instructions and specifications for the Integrated OCE that will be utilized under the Outpatient Prospective Payment System (OPPS) and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness. The attached recurring update notification applies to publication 100-04, chapter 4, section EFFECTIVE DATE: January 1, 2022 *Unless otherwise specified, the effective date is the date of service.

2 IMPLEMENTATION DATE: January 3, 2022 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE N/A N/A III. FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

3 IV. ATTACHMENTS: Recurring Update Notification Attachment - Recurring Update Notification Pub. 100-04 Transmittal: 11149 Date: December 10, 2021 Change Request: 12533 SUBJECT: January 2022 Integrated Outpatient code Editor (I/OCE) Specifications Version EFFECTIVE DATE: January 1, 2022 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 3, 2022 I. GENERAL INFORMATION A. Background: This instruction informs the A/B Medicare Administrative Contractors (MACs) Part A, the A/B MACs Part Home Health and Hospice (HHH) and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2022. The I/OCE routes all institutional outpatient claims (which includes Non-Outpatient Prospective Payment System [non-OPPS] hospital claims) through a single integrated OCE. The attached recurring update notification applies to publication 100-04, chapter 4, section B. Policy: This notification provides the Integrated OCE instructions and specifications for the Integrated OCE that will be utilized under the OPPS and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness.

4 The I/OCE specifications will be posted to the CMS website and can be found at II. BUSINESS REQUIREMENTS TABLE "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility A/B MAC DME MAC Shared- System Maintainers Other A B HHH FISS MCS VMS CWF The Shared System Maintainer shall install the Integrated OCE (I/OCE) into their systems. X Medicare contractors shall identify the I/OCE specifications on the CMS website at X X X III. PROVIDER EDUCATION TABLE Number Requirement Responsibility A/B MAC DME MAC CEDI A B HHH Medicare Learning Network (MLN): CMS will market provider education content through the MLN Connects newsletter shortly after CMS releases the CR. MACs shall follow IOM Pub. No. 100-09 Chapter 6, Section instructions for distributing the MLN Connects newsletter information to providers and link to relevant information on your website. You may supplement MLN content with your local information after we release the MLN Connects newsletter.

5 Subscribe to the MLN Connects listserv to get MLN content notifications. You don t need to separately track and report MLN content releases when you distribute MLN Connects newsletter content per the Manual section referenced above. X X IV. SUPPORTING INFORMATION Section A: Recommendations and supporting information associated with listed requirements: N/A "Should" denotes a recommendation. X-Ref Requirement Number Recommendations or other supporting information: Section B: All other recommendations and supporting information: N/A V. CONTACTS Pre-Implementation Contact(s): Yvonne Young, , Marina Kushnirova, , Fred Rooke, Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR). VI. FUNDING Section A: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work.

6 The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. ATTACHMENTS: 2 2 Summary of Quarterly Release Modifications The modifications of the IOCE for the January 1, 2022, release is summarized in the table below. Readers should also read through the entire document and note the highlighted sections, which also indicate changes from the prior release of the software. Some IOCE modifications in the update may be retroactively added to prior releases. If so, the retroactive date appears in the 'Effective Date' column. Item # Type Effective Date Edits Affected Modification 1.

7 Logic 01/01/2022 24 Modify the software to maintain 28 prior quarters (7 years) of programs in each release. Remove older versions with each release. The earliest date/version included for this release is 04/01/2015, of the IOCE. 2. Logic 01/01/2022 Logic related to modifier PT for colorectal screening is updated to include a gradual waiver of coinsurance for colorectal cancer screenings and other surgical services reported on the same day, in addition to the waiver of the deductible (new Payment Adjustment Flag 25). This change in logic adds category III CPT code range 0000T-9999T, in addition to the surgical range codes (10000-69999). 3. Logic 04/01/2021 Implement new logic for the Opioid Use Disorder (OUD) demonstration model, which requires a waiver of deductible and coinsurance for office-based OUD treatment HCPCS when reported with Condition code M5 (Payer code defining OUD demo claims) for specific OPPS bill types. 4. Logic 04/01/2021 Implement new logic for the Opioid Use Disorder OUD demonstration model for FQHC claims to return a packaging flag of 6 (FQHC packaged preventive or other reported service not subject to coinsurance payment) for office-based OUD HCPCS that are reported on an OUD model claim reporting Condition code M5 for FQHC bill type 77x.

8 5. Logic 01/01/2022 Implement new logic for Radiation Oncology Model (ROM) HCPCS, that when reported on 013x bill type claims, Payment Method Flag B (Radiation oncology model service with payment reduction applied) is returned indicating the APC payment is reduced. 6. Logic, Documentation 04/01/2015 83 Update the Edits Applied by Bill Type table to include edit 83 for OPPS (documentation only) and Non-OPPS (program logic) for bill type 087x. 7. Logic 04/01/2015 Update the program logic related to the Edits Applied by Bill Type table (OPPS), specific to bill type 075x (CORF) when Condition code 07 is present and antigens, splints or casts are reported, to indicate that the APC return buffer is completed. 8. Logic 04/01/2015 73 Update the Blood and Blood Storage Processing program logic to correctly return edit 73 on subsequent days of the same claim where blood product services are reported. 9. Logic 01/01/2022 110 Apply mid-quarter edit 110 (initial marketing date) to the following HCPCS codes: 0004A: 09/22/2021 0034A: 10/20/2021 0064A: 10/20/2021 0071A: 10/29/2021 0072A: 10/29/2021 91306: 10/20/2021 91307: 10/29/2021 10.

9 Logic 01/01/2022 68 Apply mid-quarter edit 68 (NCD approval) to the following HCPCS codes: G0465: 04/13/2021 11. Logic 07/16/2021 67 Apply mid-quarter edit 67 (FDA approval) to the following HCPCS code : 90671: 07/16/2021 12. Logic 01/01/2022 22 Add new modifiers to the valid modifier list: FQ: Audio-only service FR: Two-way a/v dir supervision FS: Split or shared e/m visit FT: Separate, unrelated e/m 13. Documentation 04/01/2021 Add new Payment adjustment flag 25 (Deductible not applicable and Coinsurance reduced) to the APC Return Buffer Table. 14. Documentation 04/01/2021 Update the description for Packaging Flag 6 (FQHC packaged preventive or other reported service not subject to coinsurance payment) to include non-preventive services that may be subject to coinsurance waiver. 15. Documentation 01/01/2022 Update the description for Payment Method Flag B (Radiation oncology model service with payment reduction applied) in the Payment Method Flag Value table.

10 16. Documentation 01/01/2022 Update the Edit Descriptions and Reason for Edit Generation Table to include a reserved list of edit numbers 120-199 for future use. 17. Documentation 01/01/2022 Remove and/or note the following items and sections of logic that have now gone out of scope: Removed Payment Adjustment Flag 3 from the APC Return Buffer table. Edit 96 and 97 were retroactively deleted 7/1/2016 and are now noted as inactive within the Edit Descriptions table and removed from the applicable Edits by Bill types tables. Payment Adjustment Flag (PAF) Value Condition Settings/Notes section to include a note for the deactivation of PAF values 1 and 2. Payment Adjustment Flag (PAF) table values 7 and 8 are noted as discontinued effective January 2014 ( ). Item # Type Effective Date Edits Affected Modification 18. Content 10/01/2021 Make all Diagnosis, HCPCS, APC, SI and edit changes as specified by CMS. Updates were made to the following tables and lists.