Reason Code Narrative

SERVICE ON THE SAME DAY AS INPATIENT PROCEDURE (LINE-ITEM DENIAL)

Common Reason Code Errors

• Outpatient items and services submitted with an inpatient procedure are not payable under outpatient prospective payment system (OPPS)
  • All other line items on the same day as the line with a C status indicator are denied (line item denial/rejection flag = 1, APC return buffer)
    • For example, OCE System Flag 1:
      HCPCS with a status indicator ‘C’ are inpatient procedures and are not considered payable
• Reference the status indicator which identifies if the HCPCS code is paid under OPPS prior to claim submission
• The full list of status indicators and their definitions is published in Addendum D1 of the OPPS/ASC proposed and final rules each year

Common Reason Code Corrections

• If the HCPCS code is incorrect, you may request a corrected claim to appeals
• Direct Data entry (DDE) - The process for reviewing OCE flag status indicators for the desired HCPCS codes is as follows:
  • Open the claim and go to 02 (MAP171)
  • Press the “F2” or “F11” key to review the line items details (MAP171A)
  • Review the OCE flag status (IND) 1 field

Resources

• HCPCS codes and their status indicators, APC groups and OPPS payment rates are posted quarterly to the OPPS website under Hospital Outpatient PPS, Addendum A and Addendum B Updates
• Refer to Outpatient Code Editor (OCE) which edits a claim for accuracy of submitted data in determining if packaging is applicable

View reason code list, return to Reason Code Guidance page.