Hospitals are required to use HCPCS when billing for outpatient services.

The APC system establishes groups of covered services so that the services within each group are comparable clinically and with respect to the use of resources. The APC-based OPPS developed by CMS is the outpatient equivalent of the inpatient, DRG-based PPS. Final regulations were published in the ApFederal Register and the system became effective for Medicare on August 1, 2000. CMS released the proposed OPPS rules using the Ambulatory Payment Classification (APC) system in the SeptemFederal Register. The OPPS functionality of the Integrated Outpatient Code Editor (I/OCE) software was developed for the implementation of the Medicare outpatient prospective payment system mandated by the 1997 Balanced Budget Act. It also did not compute any information for payment purposes. Prior to OPPS, the software focused solely on editing claims without specifying any action to take when an edit occurred. 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.Īppendix A contains lists of codes associated with program edits for both OPPS and non-OPPS processing. Purpose of the non-OPPS I/OCE functionality

Determines payment adjustment, if applicable.

Determines a claim disposition based on generated edits.

Assigns CMS-designated status indicators.

Edits a claim for accuracy of submitted data.

The software performs the following functions when processing a claim: The Integrated Outpatient Code Editor (I/OCE) software combines editing logic with the new APC assignment program designed to meet the mandated OPPS implementation.

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