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Last Modified: 9/12/2024 Location: FL, PR, USVI Business: Part A

Activation of systematic validation edits for OPPS providers with multiple service locations

Summary

Increasingly, hospitals operate an off-campus, outpatient, provider-based department of a hospital. In some cases, these additional locations are in a different payment locality than the main provider. For Medicare physician fee schedule (MPFS) and outpatient prospective payment system (OPPS) payments to be accurate, CMS uses the service facility address of the off-campus, outpatient, provider-based department of a hospital facility to determine the locality in these cases.
Additionally, regulations require non-excepted services provided at an off-campus, outpatient, provider-based department of a hospital to be identified as the payment rate for non-excepted items and services billed on an institutional claim are to be paid under the MPFS and not the OPPS rates.
On August 1, 2023, CMS will deploy full production activation editing for JN providers based on the implementation schedule outlined below. MACs, such as First Coast, are instructed to permanently turn on editing for reason codes 34977, 34978, 34984, 34985, 34986, and 34987. These reason codes will be set up to return to provider (RTP) claims that do not match exactly. Validation will be exact matching based on the information on the CMS-855A form submitted by the provider and entered in PECOS.
The reason code implementation schedule is as follows:

Implementation Date
Reason Code(s)
Region
8/1/2023
34977 and 34978
Puerto Rico and US Virgin Islands
8/8/2023
34977 and 34978
Florida
9/5/2023
34984 and 34985
All states in JN
9/12/2023
34986 and 34987
All states in JN
How can you prepare?
Verify your practice addresses in PECOS
If any locations are not in PECOS, submit the CMS-855A enrollment form to add locations
Ensure your enrollment information is up to date and claim submissions reflect the practice locations exactly as it appears from the practice location address screen received from PECOS and viewed in the Fiscal Intermediary Standard System (FISS) under Short Cut 1D Provider Practice Address
Ensure claims are submitted with the practice location as listed in direct data entry (DDE) and PECOS (e.g., Road vs. Rd, Suite vs. Ste. etc.)
Include special characters if listed in the address (e.g., ! &, (), +, *, ;, : etc.)
Full edit implementation
Claims will RTP with the following reason codes:
34977: Claim service facility address doesn’t match provider practice file address
34978: Off-campus provider claim line that contains a HCPCS code must have a PN, PO, or ER
34984: Modifier ER is not present on the claim and practice location reported is a dedicated emergency department (ED)
34985: Modifier PO is not present on the claim and a practice location is reported. Refer to SE18002
34986: Modifier PN is not present on the claim and a practice location is reported that has a practice effective date on/after 11/2/15. Refer to SE18002
34987: Condition code A7 is present on the claim and the location reported is not a mobile facility and/or portable units
Correct service facility address for claim submitted in DDE MAP 171F screen
Submit new 855A form to add a new or correct an existing practice location address
Reporting the provider practice location
Providers will report the service facility location for an off-campus, outpatient, provider-based department of a hospital as follows on the claim ensuring it is an exact match to what is in PECOS.
For electronic claims, report in the 2310E loop of the 837 institutional claim transaction
For DDE or FISS, report in MAP171F
Claim page 3 extended, press F11 two times
For paper submitters on the UB-04, report in form locator 01
Additional resources
View complete special edition MLN Matters® article at: SE18002 and SE19007 external pdf file.
Source: SE 19007
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.