Or. Admin. Code § 410-140-0415

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-140-0415 - Codes

(1) Providers shall use an International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) diagnosis code on all claims.

(2) Providers shall provide the member's diagnosis to ancillary service providers (e.g., SWEEP Optical Laboratories) when prescribing services, equipment, and supplies.

(3) Providers shall use the standardized code sets required by the Health Insurance Portability and Accountability Act (HIPAA) and adopted by the Centers for Medicare and Medicaid Services (CMS). Providers shall accurately code claims using the combination of Health Care Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes in effect for the date the service was provided:

(a) Providers may not bill CPT or HCPCS procedure codes for separate procedures when a single CPT or HCPCS code includes all services provided. Providers shall comply with published coding guidelines;

(b) Intermediate and comprehensive ophthalmological services as described under the ophthalmology section of the CPT codebook shall be billed using codes included under this section and not those included under the Evaluation and Management section;

(c) When there is no appropriate descriptive procedure code to bill the Division, the provider shall use the code for "unlisted services."

(4) The Division recognizes HIPAA compliant modifiers in coding.

(5) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

Or. Admin. Code § 410-140-0415

DMAP 127-2024, adopt filed 10/08/2024, effective 10/8/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: 414.025, 414.065, 414.591 & 414.631