New diagnostic radiopharmaceutical edits

Effective January 1, 2008, the Outpatient Code Editor (OCE) will begin editing for the presence of a HCPCS code for the diagnostic radiopharmaceutical on the same claim as the separately payable nuclear medicine procedure. Claims not passing these edits will be returned to the provider. The nuclear medicine procedure-radiopharmaceutical edits are available on the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/ under Downloads. These edits may be updated quarterly as appropriate. ...

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Note:  The following article synopsis was NOT provided by the AHA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article explains a Medicare outpatient claims editing change tied to diagnostic radiopharmaceutical reporting and nuclear medicine procedures, effective in 2008. It is relevant to hospital outpatient coding staff, billing teams, and anyone tracking CMS Outpatient Code Editor updates and the related downloadable edit files.

Why This Topic Matters

Readers need to know about the claim-processing change so they can recognize when outpatient claims may be returned and where CMS posts the related edit information.

What You Will Learn

  • What the article covers in CMS outpatient claim editing
  • How the update relates to nuclear medicine and diagnostic radiopharmaceutical claims
  • Where CMS provides the related edit files
  • Why quarterly updates may matter for billing workflow

Who Should Read This

  • Hospital outpatient coders
  • Billing and claims staff
  • Revenue cycle personnel
  • Compliance teams
  • Medical coding professionals

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