In The Know: Introduction to the IOCE V20.3

November 19, 2019

All institutional outpatient claims, regardless of facility type, process through the Integrated Outpatient Code Editor (IOCE). The IOCE is a program utilized by Medicare Administrative Contractors (MAC) for outpatient hospitals both subject to and not subject to the Outpatient Prospective Payment System (OPPS).

The IOCE performs two major functions:

  1. Edit the claims 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 to be used as input to an OPPS PRICER program. For Non-OPPS claims, a series of Non-OPPS applicable edits are returned.

All applicable services should be submitted as a single claim record to the IOCE. The IOCE only functions on a single claim and does not have any cross-claim capabilities. The IOCE accepts up to 450-line items per claim. The IOCE software is responsible for ordering line items by date of service. The span of time that a claim represents is controlled by the From and Through dates identified on the claim. If the claim spans more than one calendar day, the IOCE subdivides the claim into separate days for the purpose of determining discounting and multiple visits on the same calendar day.

The IOCE identifies individual 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. The IOCE performs all functions referencing HCPCS codes, modifiers and ICD-10-CM diagnosis codes. Since these coding systems are complex, the centralization of the direct reference to these codes and modifiers in a single program reduces effort and reduces the chance of inconsistent processing of claims.

The current version includes 111 edits. We highlighted 27 edits below of specific interest to outpatient coders.

EditEdit DescriptionReason for Edit GenerationDisposition
1Invalid diagnosis codeThe principal diagnosis field is blank, there are no diagnoses entered on the claim, or the entered diagnosis code is not valid.RTP
2Diagnosis and age conflictThe diagnosis code includes an age range, and the age reported is outside that range.RTP
3Diagnosis and sex conflictThe diagnosis code includes sex designation, and the sex does not match. This edit is bypassed if condition code 45 is present on the claim.RTP
5External cause of morbidity code cannot be used as principal diagnosisThe diagnoses reported is considered a morbidity code and cannot be used as the principal diagnosesRTP
6Invalid procedure codeThe entered HCPCS code is not valid for the selected version of the program.RTP
8Procedure and sex conflictThe sex of the patient does not match the sex designated for the procedure code reported. This edit is bypassed if condition code 45 is present on the claim.RTP
12Questionable covered serviceThe procedure reported is flagged as a Questionable covered service.Suspend
17Inappropriate specification of bilateral procedureThe same inherent bilateral procedure code occurs two or more times on the same service date. This edit is applied to all relevant bilateral procedure lines, except when modifier 76 or 77 is submitted on the second or subsequent line or units of an inherently bilateral code. Note: For codes with an SI of V that are also on the Inherent Bilateral list, condition code G0 will take precedence over the bilateral edit; these claims will not receive edit 17. This edit is also bypassed if the bill type is 85x.RTP
20Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is presentThe second procedure reported is part of an NCCI pair, which will cause the generation of edit 20 to LIR even in the presence of a modifier.LIR
21Medical visit on the same day as a type T or S procedure without modifier 25One or more type T or S procedures occur on the same day as a line item containing an E&M code, without modifier 25.RTP
22Invalid modifierThe modifier is not in the list of valid modifier entries and the revenue code is not 540.RTP
23Invalid dataThe service date and/or the from and through dates are invalid. Or the Service date falls outside the range of the From and Through dates. This edit terminates processing for the claim.RTP
27Only incidental services reportedAll line items are incidental (status indicator N). If edit 27 is present no other edits are performed.Claim Rejection
37Terminated bilateral procedure or terminated procedure with units greater than oneA modifier 52 or 73 is present, as well as: an independent or conditional bilateral procedure with modifier 50 or a procedure with units greater than 1.RTP
40Code2 of a code pair that would be allowed by NCCI if appropriate modifier were presentThe procedure is identified as part of another procedure on the claim coded on the same day, where the modifier was either not coded or is not an NCCI modifier. Only the code in column 2 of a code pair is rejected; the column 1 code of the pair is not marked as an edit.LIR
42Multiple medical visits on same day with same revenue code without condition code G0Multiple 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.RTP
43Transfusion or blood product exchange without specification of blood productA blood transfusion or exchange is coded but no blood product is reported.RTP
44Observation revenue code on line item with non-observation HCPCS codeA 762 (observation) revenue code is used with a HCPCS other than observation 99217-99220, 99234-99236, G0378, reported.RTP
48Revenue center requires HCPCSThe bill type is 13x, 74x, 75x, 76x, or 12x/14x without condition code 41, HCPCS is blank, and the revenue center status indicator is not N or F. This edit is bypassed when the revenue code is 100x, 210x, 310x, 099x, 0905-0907, 0500, 0509, 0583, 0660-0663, 0669, 0931, 0932, 0521, 0522, 0524, 0525, 0527, 0528, 0637, or 0948; see also edit 65.RTP
60Use of modifier CA with more than one procedure not allowedModifier CA is present on more than one line or Modifier CA is submitted on a line with multiple units.RTP
70CA modifier requires patient discharge status indicating expired or transferredCA modifier requires patient discharge status indicating expired or transferred.RTP
73Incorrect billing of blood and blood productsBlood product claims lack two identical lines (of HCPCS code, units, and modifier BL), one line with revenue code 38x and the other line with revenue code 39x.RTP
74Units greater than one for bilateral procedure billed with modifier 50Any code on the Conditional or Independent bilateral list is submitted with modifier 50 and units of service are greater than one on the same line.RTP
79Incorrect billing of revenue code with HCPCS codeThe revenue code is 381 with a HCPCS code other than packed red cells (P9016, P9021, P9022, P9038, P9039, P9040, P9051, P9054, P9057, P9058) or The revenue code is 382 with a HCPCS code other than whole blood P9010, P9051, P9054, and P9056).RTP
84Claim lacks required primary codeCertain claims are returned to the provider if a specified add-on code is submitted without a code for a required primary procedure on the same date of service (edit 84). Add-on codes 33225, 90785, 90833, 90836 or 90838 are submitted without one of the required primary codes on the same day.RTP
86Manifestation code not allowed as principal diagnosisA diagnosis code considered to be a manifestation code from the Medicare Code Editor (MCE) manifestation diagnosis list is reported as the principal diagnosis code on a hospice bill type claim 81X, 82X.RTP
92Device-dependent procedure reported without device codeA device-dependent procedure is reported without a device code.RTP

For more information on the index, check out CMS.

Lisa Marks, VP of HIM Services