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 10540 Date: December 31, 2020 Change Request 12114 SUBJECT: January 2021 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, 2021 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 4, 2021 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material.

2 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: 10540 Date: December 31, 2020 Change Request: 12114 SUBJECT: January 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version EFFECTIVE DATE: January 1, 2021 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 4, 2021 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, 2021. 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 MLN Article: CMS will make available an MLN Matters provider education article that will be marketed through the MLN Connects weekly newsletter shortly after the CR is released. MACs shall follow IOM Pub. No. 100-09 Chapter 6, Section , instructions for distributing MLN Connects information to providers, posting the article or a direct link to the article on your website, and including the article or a direct link to the article in your bulletin or newsletter.

5 You may supplement MLN Matters articles with localized information benefiting your provider community in billing and administering the Medicare program correctly. Subscribe to the MLN Matters listserv to get article release notifications, or review them in the MLN Connects weekly newsletter. 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.

6 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. ATTACHMENTS: 2 Final Summary of Data Changes IOCE January 2021 Final Summary of Data Changes Page 2 of 102 Table of Contents Diagnosis Code 5 Added ICD-10-CM Diagnosis Codes .. 5 Deleted ICD-10-CM Diagnosis Codes .. 6 Unacceptable Principal Diagnosis Additions .. 7 Unacceptable Principal Diagnosis (OPPS) Exclusion Additions .. 8 APC Changes .. 9 Added APCs .. 9 Deleted APCs.

7 10 Modified APC Descriptions .. 11 Modified APC Status Indicators .. 12 Added Comprehensive APCs .. 13 APC Payment Offsets Modified .. 14 HCPCS Procedure Code Changes .. 15 Added HCPCS Codes .. 15 Deleted HCPCS CPT Codes .. 19 Modified HCPCS Code Descriptions .. 22 Modified HCPCS Code APC/Status Indicators/Edit Assignments .. 25 Mid Quarter Edits Additions .. 33 Male Only HCPCS Additions .. 34 Male Only HCPCS Removals .. 35 Female Only HCPCS Additions .. 36 Female Only HCPCS Removals .. 37 Conditional Bilateral Additions .. 38 Conditional Bilateral Removals .. 39 Independent Bilateral 40 Inherent Bilateral Additions .. 41 Inherent Bilateral Removals .. 42 Deductible Coinsurance Not Applicable Additions .. 43 Deductible Coinsurance Not Applicable Removals .. 44 Coinsurance And Deductible Waiver Eligible Removals .. 45 Blood Product Additions .. 46 Separate Procedure Removals .. 47 Bypass Edit 99 Additions .. 48 Non-Standard CT Scan Equipment Procedure Additions .. 49 Radiology Procedure For Payment Adjustment Removals.

8 50 Comprehensive APC HCPCS Additions .. 51 Comprehensive APC HCPCS Removals .. 55 Complexity Adjusted Code Pair Additions .. 56 Complexity Adjusted Code Pair Removals .. 59 CAPC Exclusion Additions .. 62 CAPC Exclusion Removals .. 63 Opioid Treatment Program Services Additions .. 64 FQHC Qualifying Visit Code Pair Removals .. 65 FQHC Flu PPV Additions .. 66 FQHC Non-Covered Additions .. 67 Final Summary of Data Changes Page 3 of 102 FQHC Non-Covered Removals .. 68 FQHC Preventive Services Additions .. 69 Vaccine Administration Services Additions .. 70 Pass-Through Radiopharm HCPCS Additions .. 72 Pass-Through Radiopharm HCPCS Removals .. 73 Skin Substitute High Cost Product Additions .. 74 Skin Substitute Low Cost Product 75 Device 76 Device Procedure Additions .. 77 Device Procedure Removals .. 80 Device Procedure Edit 92 Bypass Additions .. 81 Device Procedure Edit 92 Bypass Removals .. 82 Pass-Through Device HCPCS Additions .. 83 Pass-Through Device HCPCS Removals .. 84 Pass-Through Device Offset Procedure 85 Pass-Through Device Offset Procedure Removals.

9 86 Pass-Through Device Offset Procedure Modifications .. 87 Terminated Device Procedure Additions .. 88 Terminated Device Procedure Removals .. 91 Terminated Device Procedure Modifications .. 92 Covid-19 Laboratory Addon Procedure Code Additions .. 97 Type One Addon Procedure Code Additions .. 98 Type One Addon Procedure Code Removals .. 99 Type Three Addon Procedure Code Additions .. 100 Type Three Addon Procedure Code Removals .. 101 Final Summary of Data Changes Page 4 of 102 CPT codes, descriptions and material only are copyright 2020 American Medical Association. All rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained herein. All rights reserved. Final Summary of Data Changes Page 5 of 102 Diagnosis Code Changes Added ICD-10-CM Diagnosis Codes The following ICD-10-CM Diagnosis code(s) were added.

10 Added ICD-10-CM Diagnosis Codes Diagnosis Eff Date Description J1282 2021-01-01 Pneumonia due to coronavirus disease 2019 M3581 2021-01-01 multisystem inflammatory syndrome M3589 2021-01-01 Other specified systemic involvement of connective tissue Z1152 2021-01-01 Encounter for screening for COVID-19 Z20822 2021-01-01 Contact with and (suspected) exposure to COVID19 Z8616 2021-01-01 Personal history of COVID-19 Final Summary of Data Changes Page 6 of 102 Deleted ICD-10-CM Diagnosis Codes The following ICD-10-CM Diagnosis code(s) were deleted. Deleted ICD-10-CM Diagnosis Codes Diagnosis Eff Date Description M358 2021-01-01 Other specified systemic involvement of connective tissue Final Summary of Data Changes Page 7 of 102 Unacceptable Principal Diagnosis Additions The following ICD-10 code(s) were added to the Unacceptable Principal Diagnosis list (edit 113). Unacceptable Principal Diagnosis Additions Reason Key: A=Added To List, N=New Code Diagnosis Eff Date Description R* J1282 2021-01-01 Pneumonia due to coronavirus disease 2019 N Z1152 2021-01-01 Encounter for screening for COVID-19 N Z20822 2021-01-01 Contact with and (suspected) exposure to COVID19 N Z8616 2021-01-01 Personal history of COVID-19 N Final Summary of Data Changes Page 8 of 102 Unacceptable Principal Diagnosis (OPPS) Exclusion Additions The following ICD-10 code(s) were added as OPPS exclusions from the Unacceptable Principal Diagnosis list (edit 113 exclusions).