Frequently Asked Questions
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FAQ

What's the difference between the Outpatient Code Editor edits and the CCI edits?

The OCE edits and the CCI edits are two editing systems used to process fiscal intermediary (hospital outpatient) and carrier-related claims, respectively. The CCI edits are developed based on coding conventions defined in the AMA's CPT Manual, current standards of medical and surgical coding practice, input from specialty societies, and based on analysis of current coding practice. The CCI edits are used for carrier processing of physician services under the Medicare Physician Fee Schedule while the OCE edits are used by intermediaries for processing hospital outpatient services under the Hospital OPPS.

The OCE is used in processing OPPS claims. Within the OCE are over 50 OCE edits, which determine whether a specific code is payable under the hospital OPPS. Many of the CCI edits are included in the OCE edits (see edit #19, 20, 39, and 40 below). The OCE edits are used exclusively under the hospital OPPS - they are not used within the Medicare Physician Fee Schedule.

The CCI edits always consist of pairs of HCPCS codes, and are arranged in two tables. One is the column 1/column 2 correct coding edits table, and the other is known as the mutually exclusive edits table. The OCE edits are arranged in numerical order with descriptions for each edit, as well as a claim disposition for each edit. Examples of OCE edits are listed below. For further information on the latest OCE edits within the hospital OPPS, please visit our website at http://www.cms.hhs.gov/Manuals/  to find the latest transmittal (program memorandum) on the OCE.
EditDescriptionDisposition1Invalid diagnosis codeReturn to Provider (RTP)2Diagnosis and age conflictRTP3Diagnosis and sex conflictRTP4Medicare secondary payer alertSuspend19Mutually exclusive procedure that is not allowed by CCI even if appropriate modifier is presentLine Item Rejection20Component of a comprehensive procedure that is not allowed by CCI even if appropriate modifier is presentLine Item Rejection39Mutually exclusive procedure that would be allowed by CCI if appropriate modifier were presentLine Item Rejection40Component of a comprehensive procedure that would be allowed by CCI if appropriate modifier were presentLine Item Rejection
(FAQ1909)

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