![]() The I/OCE only functions on a single claim and does not have any cross claim capabilities. It is the user's responsibility to organize all applicable services into a single claim record and pass them as a unit to the software. Each claim is represented by a collection of data, consisting of all necessary demographic (header) data, plus all services provided (line items). In this case, the line item cannot be resubmitted but can be appealed.Ī major change is the processing of claims with service dates that span more than one day. For example, an edit can cause a line item to be denied payment while still allowing the claim to be processed for payment. The revised program indicates what actions to take when an edit occurs, and the reason(s) why the actions are necessary. While the software has maintained the editing logic of previous versions, assignment of APC numbers for services has been added to meet Medicare's mandated OPPS implementation. If a patient has multiple outpatient services during a single visit, the total payment for the visit is computed as the sum of the individual payments for each service. ![]() However, unlike the inpatient system that assigns a patient to a single DRG, multiple APCs can be assigned to one outpatient record. Like the inpatient system based on Diagnosis Related Groups (DRG's), each APC has a pre-established prospective payment amount associated with it.
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