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Part A Noridian Custom Edits (NCE)

To decrease the provider burden associated with claim-related administrative costs, Noridian is integrating Noridian Custom Edits (NCE) into our EDI gateway for electronic claims processing. NCE enhance claims editing for both providers and payers and integrate with existing claims acknowledgement reporting (277CA) on 837 electronic claim submissions.

NCE allow Noridian to:

  • Help identify problematic or "certain to deny" claims prior to Noridian claims processing
  • Alert providers of errors and potential claim processing issues around medical necessity, non-covered services, missing modifiers, and other clinical editing
  • Deliver timely and clear notifications of how to fix claim errors
  • Save administrative time tied to claim resubmissions
  • Improve transparency of claim editing and claims processing
  • Provide information or reminders on claim submissions

NCE populate in the STC elements of the 277CA with distinct code sets that can be cross referenced to the NCE table below.

STC A3:23:41 will display rejection messages.

STC A2:20:41 will display informational messages which do not cause the claim to reject.

Note: Claims rejected by NCE editing are not sent through the claims processing system. If you are seeking a denial, remittance advice, or do not wish to make any corrections, simply resubmit the claim.

NCE Flag NCE Rule ID NCE Message NCE Expression
002IAG 27742 [Pattern 27742] The principal diagnosis code <1> is for maternity and is not typical for the patient age of <2> years. This outpatient edit will set when the principal diagnosis code is identified as a maternity age classification and the age of the patient is less than 12 or greater than 55.
002IAG 13256 [Pattern 13256] The other diagnosis code <1> is for adolescents and is not typical for the patient's age <1> years. This outpatient edit will set when a diagnosis code is identified as an adolescent age classification and the age of the patient is greater than 17.
002IAG 17605 [Pattern 17605] The principal diagnosis code <1> is for newborns and is not typical for the patient's age of <1> years. This outpatient edit will set when the principal diagnosis code is identified as a Newborn classification and the age of the patient is greater than Zero.
002IAG 17606 [Pattern 17606] The principal diagnosis code <1> is for adolescents and is not typical for the patient's age of <1> years. This outpatient edit will set when a diagnosis code is identified as an adolescent age classification and the age of the patient is greater than 17.
002IAG 17607 [Pattern 17607] The principal diagnosis code <1> is for maternity and is not typical for the patient's age of <1> years. This outpatient edit will set when the principal diagnosis code is identified as a maternity age classification and the age of the patient is less than 12 or greater than 55.
002IAG 17608 [Pattern 17608] The principal diagnosis code <1> is for adults and is not typical for the patient's age of <1> years. This outpatient edit will set when a diagnosis code is identified as an adult age classification and the age of the patient is less than 15.
002IAG 17610 [Pattern 17610] The other diagnosis code <1> is for newborns and is not typical for the patient's age of <1> years. This outpatient edit will set when the principal diagnosis code is identified as a Newborn classification and the age of the patient is greater than Zero.
002IAG 17615 [Pattern 17615] The other diagnosis code <1> is for maternity and is not typical for the patient's age of <1> years. This outpatient edit will set when a diagnosis code is identified as a maternity age classification and the age of the patient is less than 12 or greater than 55.
002IAG 17616 [Pattern 17616] The other diagnosis code <1> is for adults and is not typical for the patient's age of <1> years. This outpatient edit will set when a diagnosis code is identified as an adult age classification and the age of the patient is less than 15.
002IAG 18385 [Pattern 18385] The reason for visit diagnosis code <1> is for adolescents and is not typical for the patient's age of <1> years. This outpatient edit will set when a diagnosis code is identified as an adolescent age classification and the age of the patient is greater than 17.
002IAG 18386 [Pattern 18386] The reason for visit diagnosis code <1> is for adults and is not typical for the patient's age of <1> years. This outpatient edit will set when a diagnosis code is identified as an adult age classification and the age of the patient is less than 15.
002IAG 18387 [Pattern 18387] The reason for visit diagnosis code <1> is for newborns and is not typical for the patient's age of <1> years. This outpatient edit will set when the principal diagnosis code is identified as a Newborn classification and the age of the patient is greater than Zero.
002IAG 18388 [Pattern 18388] The reason for visit diagnosis code <1> is for maternity and is not typical for the patient's age of <1> years. This outpatient edit will set when the reason for visit diagnosis code is identified as a maternity age classification and the age of the patient is less than 12 or greater than 55.
002IAG 27741 [Pattern 27741] The reason for visit diagnosis code <1> is for maternity and is not typical for the patient's age of <1> years. This outpatient edit will set when the reason for visit diagnosis code is identified as a maternity age classification and the age of the patient is less than 12 or greater than 55.
002IAG 27743 [Pattern 27743] The other diagnosis code <1> is for maternity and is not typical for the patient's age of <1> years. This outpatient edit will set when the reason for visit diagnosis code is identified as a maternity age classification and the age of the patient is less than 12 or greater than 55.
003ISX 18849 [Pattern 18849] The other diagnosis code <1> is designated for female patients only and this conflicts with the submitted gender of the patient This outpatient edit will set when the diagnosis code describes a condition for a female gender and the patient's gender is male.
003ISX 18850 [Pattern 18850] The other diagnosis code <1> is designated for male patients only and this conflicts with the submitted gender of the patient. This outpatient edit will set when the diagnosis code describes a condition for a male gender and the patient's gender is female.
00AGAC 16780 [Pattern 16780] The Admission diagnosis code <1> is not permissible for the patients age and gender. This inpatient edit will set when the admission diagnosis code is identified as not appropriate for the patient's age and gender.
00AGAC 16783 [Pattern 16783] The Admission diagnosis code <1> is not permissible for the patients age and gender. This inpatient edit will set when the admission diagnosis code is identified as not appropriate for the patient's age and gender.
00OGAC 16784 [Pattern 16784] The Other diagnosis code <1> is not permissible for the patients age and gender. This inpatient edit will set when any other diagnosis code is identified as not appropriate for the patient's age and gender.
00OGAC 16785 [Pattern 16785] Age and gender conflict; the Other diagnosis code <1> is not permissible for the patient's age and gender. This inpatient edit will set when any other diagnosis code is identified as not appropriate for the patient's age and gender.
00PGAC 16624 [Pattern 16624] The Principal diagnosis code <1> is not permissible for the patients age and gender. This inpatient edit will set when the principal diagnosis code is identified as not appropriate for the patient's age and gender.
00PGAC 16628 [Pattern 16628] The Principal diagnosis code <1> is not permissible for the patients age and gender. This inpatient edit will set when the principal diagnosis code is identified as not appropriate for the patient's age and gender.
01ADID 20665 [Pattern 20665] The admission diagnosis code Current admitting diagnosis is invalid because it has an incomplete number of digits. This inpatient edit will set when any admitting diagnosis code has an incomplete number of digits.
01AMD 19655 [Pattern 19655] The admitting diagnosis code is missing. This inpatient edit will set when the admitting diagnosis code is missing.
01ODID 20687 [Pattern 20687] The other diagnoses codes <1> are invalid due to having an incomplete number of digits. This inpatient edit will set when an other diagnosis code has an incomplete number of digits.
01ODIP 20701 [Pattern 20701] The other procedure code <1> has an incomplete number of digits. This inpatient edit will set when an other procedure code has an incomplete number of digits.
01OIP 20700 [Pattern 20700] The other procedure code <1> is invalid. This inpatient edit will set when an other procedure code is invalid.
01PDID 20675 [Pattern 20675] The principal diagnosis code <1> is incomplete. This inpatient edit will set when the principal diagnosis code is incomplete.
01PDIP 20698 [Pattern 20698] The principal procedure code <1> is incomplete. This inpatient edit will set when the principal procedure code is incomplete.
01PIP 20689 [Pattern 20689] The principal procedure code <1> is invalid. This inpatient edit will set when the principal procedure code is invalid.
01PMD 20673 [Pattern 20673] The principal diagnosis code <1> is missing on the claim. This inpatient edit will set when the principal diagnosis code is missing on the claim.
03DDC 4690 [Pattern 4690] The other diagnoses code is a duplicate of the principal diagnosis code. This inpatient edit will set when an other diagnosis code is a duplicate to the principal diagnosis code.
03ODDC 4691 [Pattern 4691] The other diagnoses code is a duplicate of another other diagnosis code on the claim. This inpatient edit will set when an other diagnosis code is a duplicate to another other diagnosis code.
04AAGE 16850 [Pattern 16850] The Admission diagnosis <1> is not permissible for the patient age. This inpatient edit will set when the admitting diagnosis is not permissible for the patient age.
04OAGE 16853 [Pattern 16853] The Other diagnosis <1> is not permissible for the patients age. This inpatient edit will set when an other diagnosis is not permissible for the patients age.
04PAGE 7678 [Pattern 7678] Age conflict; the principal diagnosis <1> is not permissible for the patient's age. This inpatient edit will set when the principal diagnosis is not permissible for the patient's age.
05ADSX 15922 [Pattern 15922] The patient gender and Admission diagnosis code <1> on the claim are not permissible. This inpatient edit will set when the admission diagnosis code is not appropriate for the patient's gender.
05ADSX 15923 [Pattern 15923] The patient gender and Admission diagnosis code <1> on the claim are not permissible. This inpatient edit will set when the admission diagnosis code is not appropriate for the patient's gender.
05ODSX 15924 [Pattern 15924] The patient gender and other diagnosis code <1> on the claim are not permissible. This inpatient edit will set when a diagnosis code on the claim is not appropriate for the patient's gender.
05ODSX 15925 [Pattern 15925] The patient gender and other diagnosis code <1> on the claim are not permissible. This inpatient edit will set when a diagnosis code on the claim is not appropriate for the patient's gender.
05OPSX 20578 [Pattern 20578] The patient gender and Other procedure code <1> on the claim are not permissible. This inpatient edit will set when a procedure code is not appropriate for the patient's gender.
05OPSX 20579 [Pattern 20579] The patient gender and Other procedure code <1> on the claim are not permissible. This inpatient edit will set when a procedure code is not appropriate for the patient's gender.
05PDSX 15792 [Pattern 15792] The patient gender and Principal diagnosis code <1> on the claim are not permissible. This inpatient edit will set when the principal diagnosis code is not permissible for the patient's gender.
05PDSX 15793 [Pattern 15793] The patient gender and Principal diagnosis code <1> on the claim are not permissible. This inpatient edit will set when the principal diagnosis code is not permissible for the patient's gender.
05PPSX 20576 [Pattern 20576] The patient gender and Principal procedure code <1> on the claim are not permissible. This inpatient edit will set when the principal diagnosis code is not permissible for the patient's gender.
05PPSX 20577 [Pattern 20577] The patient gender and Principal procedure code <1> on the claim are not permissible. This inpatient edit will set when the principal diagnosis code is not permissible for the patient's gender.
061SBD 4489 [Pattern 4489] Code can only be billed to the DME Regional Carrier. This outpatient edit will set when non-implantable durable medical equipment (DME) code(s) are billed on a claim and need to be billed to the DME Contractor.
061SBD 7267 [Pattern 7267] Code can only be billed to the DME Regional Carrier. This outpatient edit will set when non-implantable durable medical equipment (DME) code(s) are billed on a claim and need to be billed to the DME Contractor.
061SBD 8246 [Pattern 8246] Code can only be billed to the DME Regional Carrier. This outpatient edit will set when non-implantable durable medical equipment (DME) code(s) are billed on a claim and need to be billed to the DME Contractor.
061SBD 17207 [Pattern 17207] Code can only be billed to the DME Regional Carrier. This outpatient edit will set when non-implantable durable medical equipment (DME) code(s) are billed on a claim and need to be billed to the DME Contractor.
08QAD 20527 [Pattern 20527] Principal diagnosis code <1> indicates a questionable admission. This inpatient edit will set when the principal diagnosis code is designated as insufficient justification for a hospital admission.
08QOA 25307 [Pattern 25307] Procedure code <1> indicates a questionable obstetric admission. This inpatient edit will set when a procedure code is reported for cesarean section or vaginal delivery without an outcome of delivery diagnosis code being billed.
09OUAD 5443 [Pattern 5443] Diagnosis code <1> is unacceptable as a principal diagnosis unless a required secondary diagnosis is included on the claim. This inpatient edit will set when the principal diagnosis submitted requires a secondary diagnosis which is not billed on the claim.
100AEC 5441 [Pattern 5441] An External Cause code cannot be used as the Admit diagnosis code. This inpatient edit will set when an External Cause of Injury code is billed as the admitting diagnosis.
11ANCP 21495 [Pattern 21495] Procedure code <1> is noncovered since this patients age is <2> years. This inpatient edit will set when a procedure code is non-covered due to the patient's age.
11DNCP 20891 [Pattern 20891] Procedure code <1> is noncovered when a designated diagnosis code(s) <2> is present. This inpatient edit will set when a procedure code is designated as non-covered due to specific submitted diagnosis code(s). 
11NCP 5265 [Pattern 5265] ICD procedure code(s) <1>, is non-covered. This inpatient edit will set when there are non-covered procedure codes billed on a claim.
11NCP 5268 [Pattern 5268] ICD procedure code <1> is noncovered unless exempted by a qualifying diagnosis code or procedure code. This inpatient edit will set when a non-covered procedure code is billed without a qualifying diagnosis code.
11NCP 20656 [Pattern 20656] ICD procedure code <1> is noncovered unless exempted by a qualifying diagnosis code or procedure code. This inpatient edit will set when a non-covered procedure code is billed without a qualifying diagnosis code.
14AGE 20610 [Pattern 20610] Age is invalid. <1> is not between 0 to 124 years. This inpatient edit will set when the age submitted is not between 0-124 years.
16DSC 12302 [Pattern 12302] The patient status is not valid. This inpatient edit will set when an invalid patient discharge status code is submitted.
16MDSC 12280 [Pattern 12280] The patient status code is missing. This inpatient edit will set the patient discharge status code is missing.
17ZLCP 20615 [Pattern 20615] Procedure codes 02RK0JZ and 02RL0JZ are limited coverage when Z006 diagnosis code is present. This inpatient edit will set when procedure codes 02RK0JZ and 02RL0JZ are billed on a claim with diagnosis code Z006.
18OWPP 4626 [Pattern 4626] The Other diagnosis code <1> indicates that a wrong procedure was performed. This inpatient edit will set when a diagnosis code on the claim indicates the wrong procedure was performed.
18PWPP 4625 [Pattern 4625] The Principal diagnosis code <1> indicates that a wrong procedure was performed. This inpatient edit will set when the principal diagnosis code on the claim indicates the wrong procedure was performed.
19LOS 16778 [Pattern 16778] Procedure code 5A1955Z should not be reported when the patient's length of stay is less than or equal to four days. This inpatient edit will set when procedure code 5A1955Z is billed on a claim with a length of stay of less than four days.
CCAf 12275 [Pattern 12275] The condition code on the claim is invalid. This outpatient edit will set when the condition code on the claim is invalid.
CCAf 17455 [Pattern 17455] The condition code <1> on the claim is invalid. This inpatient and outpatient edit will set when the Condition Code is not valid.
CCQf 22660 [Pattern 22660] Type of Bills with frequency code Q must have condition code W2. This inpatient and outpatient edit will set when an XXQ TOB claim does not contain a condition code W2.
CCQf 22664 [Pattern 22664] Type of Bill with frequency code Q must have a condition code D0, D1, D2, D4, D9, or E0. This inpatient and outpatient edit will set when an XXQ TOB claim does not contain a condition code D0, D1, D2, D4, D9, or E0.
CCQf 22665 [Pattern 22665] Type of Bill with frequency code Q must have a condition code from the R1-R9 range. This inpatient and outpatient edit will set when an XXQ TOB claim does not contain a condition from the R1-R9 range.
CCRCf 34503 [Pattern 34503] Type of bill <1> requires an appropriate claim change reason code. This inpatient edit will set when a correct claim change reason code is not present on an adjusted claim with TOB XX7 or XX8.
DDRERR N/A Ruleset could not be found for claim with current setup. Check route setup and ensure a default rule set has been configured. This message is returned when invalid/incorrectly formatted data is submitted on the claim. An example of invalid data would be when an invalid Type of Bill (TOB) of 0073 is submitted.
DOBf 22901 [Pattern 22901] Patient Date of Birth is missing on the claim. This inpatient edit will set when the patient's Date of Birth is missing.
DOBf 26699 [Pattern 26699] Patient's Date of Birth <1> is invalid on the claim. This inpatient edit will set when the patient's Date of Birth is invalid.
DSOf 22172 [Pattern 22172] Occurrence code 55 is required on the claim when the patient discharge status is 20. This inpatient and outpatient edit will set when patient discharge status is 20 and the claim is missing an Occurrence code 55
DUPIf 20953 [Pattern 20953] This claim is a possible duplicate claim of History Claim ID <1>. This inpatient edit will set when a possible duplicate claim is found in claim history.
ECTf 6187 [Pattern 6187] Inpatient psychiatric facility requires ICD procedure for electroconvulsive therapy. This inpatient edit will set when revenue code 0901 is billed on an inpatient psychiatric claim with no ICD procedure code present.
FTDf 6736 [Pattern 6736] Missing admission date or invalid Statement Covers Period From or Through dates. This outpatient edit will set when the claim is missing an admission date (when required) or the statement covers from and through dates are invalid.
FTDf 8152 [Pattern 8152] Missing admission date or invalid Statement Covers Period From or Through dates. This inpatient edit will set when a claim is submitted with a missing or invalid Admission date or Statement Covers Period ''From'' and ''Through'' dates
FTDf 22831 [Pattern 22831] Missing admission date or invalid Statement Covers Period From or Through dates. This inpatient edit will set when a claim is submitted with a missing or invalid Admission date or Statement Covers Period ''From'' and ''Through'' dates
IDDMf 2840 [Pattern 2840] The discharge date is missing. This inpatient edit will set when a claim is submitted with no discharge date.
IPRf 142 [Pattern 142] A principal procedure code is required when a procedure code is found in the other procedure code field. This inpatient edit will set when an inpatient claim does not contain a principal procedure when a secondary (other) procedure is present on the claim.
IRFOCf 4389 [Pattern 4389] Inpatient rehabilitation facilities TOB 011X must always submit occurrence code 50 to report assessment dates. This inpatient edit will set when revenue code 0024 is billed on an Inpatient Rehabilitation Facility (IRF) claim with Type of Bill 011X and no Occurrence Code 50 is included.
ITDf 318 [Pattern 318] HCPCS code G0257 must be submitted with TOB 013X or 085X. This outpatient edit will set when HCPCS code G0257 is submitted on a claim with a type of bill other than 013X or 085X.
JEMDf 31274 [Pattern 31274] Modifier JE is required on a drug administered via dialysate when submitted on an ESRD claim. This outpatient edit will set when a drug that is administered via dialysate (HCPC J1443) is submitted on an ESRD claim (TOB 072X) without a JE modifier.
JEMDf 26893 [Pattern 26893] Modifier JE is required on a drug administered via dialysate when submitted on an ESRD claim. This outpatient edit will set when a drug that is administered via dialysate (HCPC J1444) is submitted on an ESRD claim (TOB 072X) without a JE modifier.
MASf 197 [Pattern 197] Modifier 80, 81 or 82 must also be billed in conjunction with modifier AS. This outpatient edit will set when modifier AS is billed on a claim without modifier 80, 81, or 82.
MAXf 22756 [Pattern 22756] Modifier AX must be billed with HCPCS code J0604 or J0606. This outpatient edit will set on an ESRD (TOB 072X) claim when HCPCS J0604 or J0606 is billed without modifier AX or modifier AX is billed and HCPCS J0604 or J0606 is not on the claim.
MAXRf 22758 [Pattern 22758] When HCPCS code J0604 or J0606 is billed with modifier AX on an End Stage Renal Disease claim the revenue code must be 0636. This outpatient edit will set when HCPCS J0604 or J0606 is billed with modifier AX on an ESRD claim (TOB 072X) and the revenue code is not 0636.
MAYf 19423 [Pattern 19423] Modifier AY is not allowed on an Acute Kidney Injury claim. This outpatient edit will set when modifier AY is billed on an Acute Kidney Injury (AKI) claim.
MHFf 19658 [Pattern 19658] Only one service line per day with revenue code 0900 and a qualifying mental health visit HCPCS code Current adjusted procedure code is allowed on a RHC claim per Medicare. HCPCS code History adjusted procedure code was billed on claim ID History claim ID on claim line History claim line ID. This outpatient edit will set when a Rural Health Clinic (RHC) claim contains more than one revenue code 0900 with a mental health visit HCPC on the same date of service.
MHFf 20300 [Pattern 20300] Only one service line with revenue code 0900 and a qualifying mental health visit HCPCS code Current adjusted procedure code is allowed per date of service on a RHC claim. HCPCS code History adjusted procedure code was billed on claim ID History claim ID on claim line History claim line ID. This outpatient edit will set when a Rural Health Clinic (RHC) claim and a history claim contain more than one revenue code 0900 with a mental health visit HCPC on the same date of service.
MHFf 21791 [Pattern 21791] Only one unit of service is allowed with revenue code 0900 and a qualifying mental health visit HCPCS code per date of service on a RHC claim per Medicare. This claim contains more than one qualifying mental health visit HCPCS code Current adjusted procedure code and should not be billed with multiple units of service Current service units. This outpatient edit will set when a Rural Health Clinic (RHC) claim contains a line billed with multiple units of service under revenue code 0900 and a mental health visit HCPC.
MI10f 4295 [Pattern 4295] ICD-10 codes cannot be billed for dates of service prior to October 2, 2015, per CMS guidelines. This outpatient edit will set when an ICD-10 code is billed on a claim and the through date of service is prior to October 1, 2015, or an ICD-9 qualifier (BK, BJ, PN, PR, BN, BF, BR, and BQ) is used for an ICD-10 code.
MI10f 2936 [Pattern 2936] Per CMS guidelines ICD 10 codes cannot be billed for dates of service prior to October 1 2015. This inpatient edit will set when a claim contains an ICD-10 code type and the through date of service is prior to October 1, 2015.
MI10SCf 2935 [Pattern 2935] Medicare requires providers to split the claim, so all ICD-10 codes remain on one claim with Dates of Service beginning October 1, 2015, and later. For dates of service on or after October 1, 2015, submit with the appropriate ICD-10 codes. This outpatient edit will set when an ICD-10 code is billed on a claim with a through date prior to October 1, 2015, or an ICD-9 qualifier (BK, BJ, PN, PR, BN, BF, BR, and BQ) is used for an ICD-10 code.
MI9f 4291 [Pattern 4291] ICD-9 code types cannot be billed for dates of service greater than September 30, 2015. This outpatient edit will set when an outpatient claim contains an ICD-9 code and the through date of service is greater than September 30, 2015, or an ICD-10 qualifier (ABK, ABJ, APN, APR, ABN, ABF, BBR, and BBQ) is used for an ICD-9 code.
MI9f 2934 [Pattern 2934] ICD 9 code types cannot be billed for dates of service greater than September 30 2015. This inpatient edit will set when a claim contains an ICD-9 code type and the through date of service is greater than September 30, 2015.
MODEf 498 [Pattern 498] Modifier EE or ED must be submitted on codes J0882 or Q4081 when value code 48 is greater than 13.0 or value code 49 is greater than 39.0. This outpatient edit will set on a claim with type of bill 072X and value code 49 with an amount exceeding 39 or value code 48 with an amount exceeding 13 when HCPCS J0882 or Q4081 are billed without modifier ED or EE.
MODEf 648 [Pattern 648] Modifier EE or ED must be submitted on codes J0882 or Q4081 when value code 48 is greater than 13.0 or value code 49 is greater than 39.0. This outpatient edit will set on a claim with type of bill 072X and value code 49 with an amount exceeding 39 or value code 48 with an amount exceeding 13 when modifier EE or ED is billed without HCPCS J0882 or Q4081.
MODEf 649 [Pattern 649] Only one modifier EE or ED is appropriate for a claim line. This outpatient edit will set on a claim with type of bill 072X and value code 49 with an amount exceeding 39 or value code 48 with an amount exceeding 13 when HCPCS J0882 or Q4081 is billed with both modifiers EE and ED.
MODEf 664 [Pattern 664] Modifier EE or ED should only be used when value code 48 is greater than 13 or value code 49 is greater than 39. This outpatient edit will set on a claim with type of bill 072X when modifier EE or ED is billed and the amount for value code 48 is less than 13 or the amount for value code 49 is less than 39.
MODGf 19347 [Pattern 19347] HCPCS code 90999 is missing an appropriate Urea Reduction Ratio modifier G1-G6. This outpatient edit will set on a claim with type of bill 072X when HCPCS code 90999 is billed and the G-modifier (G1, G2, G3, G4, G5 or G6) is not present on at least one hemodialysis line on the claim.
MODJf 517 [Pattern 517] Modifier JA or JB must be submitted with code Q4081 or J0882. This outpatient edit will set on a claim with type of bill 072X when HCPCS J0882 or Q4081 is submitted without modifier JA or JB.
MODNEf 670 [Pattern 670] HCPCS codes J0881 and J0885 must be submitted with modifier EA, EB or EC. This outpatient edit will set when HCPCS J0881 or J0885 is submitted on a claim with type of bill 12X or 13X and modifier EA, EB OR EC is not submitted, or a line is submitted with more than one of the modifiers.
MODV2f 19264 [Pattern 19264] Modifier V5, V6 or V7 must be submitted with revenue code 0821. This outpatient edit will set when revenue code 0821 is billed on an ESRD claim, Type of Bill 72X, and modifier V5, V6 or V7 is not present on the line(s).
MPMf 20887 [Pattern 20887] The claim line contains a PA modifier which indicates that this surgical code was performed on the wrong body part and should be denied. This outpatient edit will set when a procedure code is billed with a modifier indicating the procedure was done in error.
MPMf 20936 [Pattern 20936] The claim line contains a PB modifier which indicates that this surgical code was performed on the wrong patient and should be denied. This outpatient edit will set when a claim line is billed with a modifier PB, indicating the procedure was performed on the wrong patient.
MPMf 20937 [Pattern 20937] The claim line contains a PC modifier which indicates that the wrong surgical code was performed on the patient and should be denied. This outpatient edit will set when a claim line is billed with a modifier PC, indicating the wrong procedure was performed on the patient.
MPNf 522 [Pattern 522] A diagnosis code that meets medical necessity for procedure code Current adjusted procedure code is missing or invalid. This outpatient edit will set when a Pneumococcal vaccine code or administration code is billed without a required diagnosis code.
MPNf 523 [Pattern 523] A diagnosis code that meets medical necessity for procedure code Current adjusted procedure code is missing or invalid. This outpatient edit will set when a Pneumococcal vaccine code or administration code is billed without a required diagnosis code.
MRCf 26530 [Pattern 26530] The required revenue code is missing or inappropriate per Medicare guidelines. This outpatient edit will set when a screening or diagnostic mammography code is submitted on an outpatient claim without the appropriate revenue code. CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 18
MRCf 26531 [Pattern 26531] The required revenue code is missing or inappropriate per Medicare guidelines. This outpatient edit will set when a screening or diagnostic mammography code is submitted on an outpatient claim without the appropriate revenue code.CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 18
MRCf 26792 [Pattern 26792] The required revenue code is missing or inappropriate per Medicare guidelines. This outpatient edit will set when a screening or diagnostic mammography code is submitted on an outpatient claim without the appropriate revenue code.CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 18
MSFf 22210 [Pattern 22210] Only one service line is allowed per day with revenue code 052X and a qualifying visit medical services HCPCS code on a RHC claim. This claim contains more than one qualifying medical services HCPCS code Current adjusted procedure code and should not be billed with multiple units of service Current service units per Medicare. This outpatient edit will set when a Rural Health Clinic (RHC) claim contains more than one service billed with revenue code 052X for the same date of service and modifier 25 or 59 is not present. Rural Health Clinics (RHCs) Reporting Requirements Frequently Asked Questions (FAQs)
MSPf 22522 [Pattern 22522] Per Medicare guidelines the diagnosis code billed does not support the medical necessity of G0101. This outpatient edit will set when HCPCS code G0101 is billed without a covered diagnosis code.
MSPHf 19668 [Pattern 19668] Procedure code Current adjusted procedure code is for either medical services or preventive health services and must be billed with revenue code 052X for Rural Health Clinic claims. This outpatient edit will set when a qualified medical service or preventive health service HCPC is billed without revenue code 052X on a Rural Health Clinic (RHC) claim, type of bill 71X.
MUEf 17681 [Pattern 17681] Per Medicare Medically Unlikely Edits the units of service billed for procedure code <Current adjusted procedure code> exceed the allowed number of units of <frequency violated policy> <Current lookup "MUE Indicators Facility" column "Flag Message".> This outpatient edit will set when the number of units billed for a procedure code on the same date of service is over the allowable amount.
MUEf 17682 [Pattern 17682] Per Medicare Medically Unlikely Edits the units of service billed for procedure code Current adjusted procedure code exceed the allowed number of units of frequency violated policy. This outpatient edit will set when the number of units billed for a procedure code on the same date of service is over the allowable amount.
MUEf 17920 [Pattern 17920] Per Medicare Medically Unlikely Edits the units of service billed for procedure code Current adjusted procedure code exceed the allowed number of units of frequency violated policy. This outpatient edit will set on a claim with Type of Bill (TOB) 85X if the number of units for a HCPC billed with a professional revenue code (0960-0969, 0970-0979, or 0980-0989), and one of the assistant surgeon modifiers (80, 81, 82, or AS), is greater than the MUE value.
MUEf 17921 [Pattern 17921] Per Medicare Medically Unlikely Edits the units of service billed for procedure code Current adjusted procedure code exceed the allowed number of units of frequency violated policy. This outpatient edit will set on a claim with Type of Bill (TOB) 85X if the number of units for a HCPC billed with a professional revenue code (0960-0969, 0970-0979, or 0980-0989) is greater than the MUE value.
MUEf 17922 [Pattern 17922] Per Medicare's Medically Unlikely Edits, the units of service billed for procedure code <Current adjusted procedure code> exceed the allowed number of units of <frequency violated policy> <Current lookup "MUE Indicators Facility" column "Flag Message".> This outpatient edit will set on a claim with Type of Bill (TOB) 85X if the number of units for a HCPC billed with a professional revenue code (0960-0969, 0970-0979, or 0980-0989), and one of the assistant surgeon modifiers (80, 81, 82, or AS), is greater than the MUE value.
MUEf 17923 [Pattern 17923] Per Medicare Medically Unlikely Edits the units of service billed for procedure code <Current adjusted procedure code> exceed the allowed number of units of <frequency violated policy> <Current lookup "MUE Indicators Facility" column "Flag Message".> This outpatient edit will set on a claim with Type of Bill (TOB) 85X if the number of units for a HCPC billed with a professional revenue code (0960-0969, 0970-0979, or 0980-0989), excluding lines billed with an assistant surgeon modifier (80, 81, 82, or AS), is greater than the MUE value.
MUEf 33875 [Pattern 33875] Per Medicare Medically Unlikely Edits the units of service billed for procedure code <Current adjusted procedure code> exceed the allowed number of units of <frequency violated policy> <Current lookup "Medicare FE MUE Table Driven By DOS" column "Flag Message".> This outpatient edit will set when the number of units billed for a procedure code on the same date of service is over the allowable amount.
MUEf 33920 [Pattern 33920] Per Medicare Medically Unlikely Edits the units of service billed for procedure code <Current adjusted procedure code> exceed the allowed number of units of <frequency violated policy> <Current lookup "Medicare FE MUE Table Driven By DOS" column "Flag Message".> This outpatient edit will set on a claim with Type of Bill (TOB) 85X if the number of units for a HCPC billed with a professional revenue code (0960-0969, 0970-0979, or 0980-0989), and one of the assistant surgeon modifiers (80, 81, 82, or AS), is greater than the MUE value.
MUEf 33924 [Pattern 33924] Per Medicare Medically Unlikely Edits the units of service billed for procedure code <Current adjusted procedure code> exceed the allowed number of units of <frequency violated policy> <Current lookup "Medicare FE MUE Table Driven By DOS" column "Flag Message".> This outpatient edit will set on a claim with Type of Bill (TOB) 85X if the number of units for a HCPC billed with a professional revenue code (0960-0969, 0970-0979, or 0980-0989), excluding lines billed with an assistant surgeon modifier (80, 81, 82, or AS), is greater than the MUE value.
N/A N/A SMARTEDIT SECURITY ID INSTITUTIONAL_DEFAULT IS NOT VALID OR ENTERPRISE DOES NOT EXIST This edit occurs when the Payer ID is not the same throughout the file.
NERf 671 [Pattern 671] HCPCS codes J0881 and J0885 must be reported with revenue code 0636. This outpatient edit will set when HCPC J0881 or J0885 is submitted without revenue code 0636 on a claim with type of bill 12X or 13X.
NTOBf Noridian0001A [DDR Noridian0001A] The type of bill code is not accepted by Noridian. This outpatient and inpatient edit will set when a claim is submitted with a type of bill Noridian does not process.
nTRCfKX Noridian0004A [DDR Noridian0004A] Reminder - Please ensure therapy services billed with modifier KX are in accordance with all applicable statutes, regulations, CMS guidelines and coverage and coding requirements. This outpatient edit will display an informational message when therapy services are billed with a KX modifier to ensure therapy services billed with modifier KX are in accordance with all applicable statutes, regulations, CMS guidelines and coverage and coding requirements.
OCCf 20999 [Pattern 20999] The occurrence code <1> on the claim is invalid. This inpatient edit will set when a claim is submitted with an invalid occurrence code.
OCCf 21005 [Pattern 21005] An occurrence code on the claim is missing the begin date. This outpatient edit will set when the occurrence code begin date is missing.
OCCf 21006 [Pattern 21006] An occurrence code on the claim is missing the begin date. This inpatient edit will set when a claim is submitted with an occurrence code and there is no begin date included.
OCD51f 19348 [Pattern 19348] Occurrence code 51 must be submitted on all ESRD claims unless value code D5 with amount 9.99 or 8.88 is present. This outpatient edit will set when a claim with Type of Bill (TOB) 72X is billed without Occurrence Code 51 or Value Code D5 with an amount of 9.99 or 8.88.
ORSf 2514 [Pattern 2514] Inappropriate type of bill or revenue code for outpatient rehabilitation service. This outpatient edit will set when HCPC 90901 or 90911 is billed with a type of bill other than 12X, 13X, 22X, 23X, 34X, 74X, 75X, and 85X.
ORSf 2515 [Pattern 2515] Inappropriate type of bill or revenue code for outpatient rehabilitation service. This outpatient edit will set when revenue code 0569 or 0911 are billed with a HCPC other than G0409.
ORSf 28149 [Pattern 28149] Inappropriate type of bill for outpatient rehabilitation service. This outpatient edit will set when an outpatient rehab biofeedback service is billed with an inappropriate type of bill.
OSCf 20886 [Pattern 20886] The occurrence span code on the claim is invalid. This outpatient edit will set when the occurrence span code on the claim is invalid.
OSCf 20978 [Pattern 20978] The occurrence span code <1> on the claim is invalid. This inpatient edit will set when a claim is submitted with an invalid occurrence span code.
OTPSf 31719 [Pattern 31719] The Opioid Treatment Program claim is missing a required revenue code. This outpatient edit will set when a claim with Type of Bill (TOB) 13X and 85X with Condition Code 89 or TOB 87X is billed and there is no Opioid Treatment Program (OTP) revenue code present, or an OTP revenue code is present but there is no OTP HCPCS code on the line.
OTPSf 31736 [Pattern 31736] The Opioid Treatment Program claim is missing a required HCPCS code. This outpatient edit will set when a claim with Type of Bill (TOB) 13X and 85X with Condition Code 89 or TOB 87X is billed and there is no Opioid Treatment Program (OTP) revenue code present, or an OTP revenue code is present but there is no OTP HCPCS code on the line.
OTSf 159 [Pattern 159] Only one therapy modifier can be reported on a line of service. This outpatient edit will set when a claim line contains more than one therapy modifier billed.
OUEDf 444 [Pattern 444] Codes Q4081 and J0882 must be submitted with code G0257. This outpatient edit will set when HCPCS J0882 or Q4081 are submitted on a claim with Type of Bill 13X or 85X and HCPCS G0257 is not present.
PDSCf 22837 [Pattern 22837] Per Medicare guidelines the patient discharge status code must be 30 when the frequency digit is the type of bill 2 or the frequency digit is the type of bill 3. This inpatient edit will set when a claim with a Type of Bill (TOB) frequency digit 2 or 3 is submitted without patient discharge status code 30 (still patient).
PMODf 1232 [Pattern 1232] Code J0890 must be reported with modifier JA or JB. This outpatient edit will set when HCPC J0890 is billed without modifier JA or JB.
POABf 21899 [Pattern 21899] Present on Admission indicator is not valid for this Type of Bill. This outpatient edit will set when a Present on Admission (POA) indicator is present on a claim with a Type of Bill (TOB) other than 11X, 18X, 21X, or 41X.
POAEf 7896 [Pattern 7896] The diagnosis code <1> is exempt from POA reporting. This inpatient edit will set when a claim contains a diagnosis that is exempt from Present on Admission (POA) and is submitted with a POA indicator other than 1 or blank for a non-exempt facility.
POAf 21906 [Pattern 21906] The Present on Admission POA indicator <1> is invalid. This inpatient edit will set when a claim contains an invalid Present on Admission (POA) indicator.
POANf 7900 [Pattern 7900] The diagnosis code <1> requires a Present on Admission indicator. This inpatient edit will set when a claim contains a diagnosis code that requires a Present on Admission (POA) indicator and the POA indicator was not billed.
PSC1f 2812 [Pattern 2812] The patient status code Current patient discharge status is invalid. This outpatient edit will set when a claim is submitted with an invalid patient discharge status code.
PSCf 2811 [Pattern 2811] The patient discharge status code is missing. This outpatient edit will set when a claim is submitted with a missing patient discharge status code.
QSTf 3720 [Pattern 3720] Per Medicare qualified stay requirements have not been met. This inpatient edit will set when occurrence code 70 has not been submitted on Type of Bills 021X or 018X.
RCNAf 19576 [Pattern 19576] Claim line revenue code Current revenue code is not allowed for RHC claims. This outpatient edit will set when a Rural Health Clinic (RHC) claim, type of bill 71X, is submitted with any of the following revenue codes 002x-024x, 045x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or 096x-310x.
RCSf 209 [Pattern 209] Must use revenue code that is to the highest specificity and 0880 is not specified. This outpatient edit will set when revenue code 0880 has been submitted on a claim with ESRD Type of Bill 72X.
RFVRf 20437 [Pattern 20437] A patient reason for visit diagnosis code is required. This outpatient edit will set when the claim is missing a required patient reason for visit diagnosis code.
RMEGf 192 [Pattern 192] Revenue code 0860 or 0861 is submitted with an inappropriate type of bill. This outpatient edit will set when revenue code 0860 or 0861 has been submitted on a claim that contains a Type of Bill other than 11X, 13X, or 85X.
RMEGf 27358 [Pattern 27358] Revenue code 0860 or 0861 is submitted with inappropriate type of bill. This inpatient edit will set when revenue code 0860 or 0861 has been submitted on a claim with a Type of Bill other than 11X, 13X or 85X.
SBPHf 275 [Pattern 275] Bills for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. This outpatient edit will set when an out-of-sequence claim for an outpatient treatment is received for Partial Hospitalization Program (PHP).
SBPHf 286 [Pattern 286] Bills for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. This outpatient edit will set when an out-of-sequence claim for an outpatient treatment is received for Partial Hospitalization Program (PHP).
SBPHf 309 [Pattern 309] Bills for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. This outpatient edit will set when an out-of-sequence claim for an outpatient treatment is received for Partial Hospitalization Program (PHP).
SBPHf 310 [Pattern 310] Bills for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. This outpatient edit will set when an out-of-sequence claim for an outpatient treatment is received for Partial Hospitalization Program (PHP).
SBPHf 311 [Pattern 311] Bills for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. This outpatient edit will set when an out-of-sequence claim for an outpatient treatment is received for Partial Hospitalization Program (PHP).
SBPHf 315 [Pattern 315] Bills for a continuous course of treatment must be submitted in the same sequence in which the services are furnished. This outpatient edit will set when an out-of-sequence claim for an outpatient treatment is received for Partial Hospitalization Program (PHP).
SBTBf 7871 [Pattern 7871] The type of bill code Current type of bill submitted on the claim is inappropriate for screening digital breast tomosynthesis. This outpatient edit will set when CPT code 77063 is billed on a type of bill other than 12x, 13x, 22x, 23x, or 85x.
SBTDf 23838 [Pattern 23838] Screening digital breast tomosynthesis HCPCS code <1> requires the appropriate diagnosis code. If you feel the appropriate diagnosis codes were used please resubmit the claim. This outpatient edit will set when a breast tomosynthesis HCPCS code is used, and the appropriate diagnosis code is not.
SBTDf 23839 [Pattern 23839] Screening digital breast tomosynthesis HCPCS code <1> requires the appropriate diagnosis code. If you feel the appropriate diagnosis codes were used please resubmit the claim. This outpatient edit will set when a breast tomosynthesis HCPCS code is used, and the appropriate diagnosis code is not.
SBTRf 7870 [Pattern 7870] Screening digital breast tomosynthesis HCPCS code Current adjusted procedure code requires the appropriate revenue code. This outpatient edit will set when CPT code 77063 is submitted without the appropriate revenue code.
SBTRf 14761 [Pattern 14761] Screening digital breast tomosynthesis HCPCS code Current adjusted procedure code requires the appropriate revenue code. This outpatient edit will set when CPT code 77063 is submitted without the appropriate revenue code.
SDBTf 23840 [Pattern 23840] Screening digital breast tomosynthesis HCPCS code <1> requires the appropriate primary mammogram code. This outpatient edit will set when codes 77063 and 77067 are not used together with the same date of service.
SNDRf 1714 [Pattern 1714] The revenue code cannot be submitted with TOB 022X This outpatient edit will set when an inappropriate revenue code is used for type of bill 022x
SNFCf 24129 [Pattern 24129] Revenue code 0022 cannot be billed with charges greater than one dollar. This inpatient edit will set when a claim with TOB 21X or 18X is submitted with a charge greater than $1.00 for revenue code 0022.
SNFDf 24122 [Pattern 24122] Per Medicare guidelines the statement covers period From and Through dates cannot span the annual update effective date of October 1. This inpatient edit will set when a claim with TOB 21X or 18X is submitted with dates of service that span October 1.
SNFHf 1417 [Pattern 1417] Revenue code 0022 requires a SNF HIPPS code. This inpatient edit will set when a claim with TOB 21X or 18X is submitted with revenue code 0022, but no Skilled Nursing Facility (SNF) HIPPS (Health Insurance Prospective Payment System) code was billed.
SNFHf 1418 [Pattern 1418] A SNF HIPPS code must be submitted with revenue code 0022. This inpatient edit will set when a claim with TOB 21X or 18X is submitted with a Skilled Nursing Facility (SNF) HIPPS (Health Insurance Prospective Payment System) code and the revenue code billed is not 0022.
SNFTf 24266 [Pattern 24266] Revenue code 0022 can only be billed on TOB 021X or 018X. This inpatient edit will set when a claim is billed with revenue code 0022 and the Type of Bill (TOB) is not a Skilled Nursing Facility (SNF) 21X or Swing Bed 18X.
SNSBf 25859 [Pattern 25859] Inpatient Skilled Nursing Facility or Swing Bed type of bill code <1> requires discharge disposition 30 when occurrence code 22 is present on the claim and the occurrence code date is equal to the through date of the claim. This inpatient edit will set when a claim with Type of Bill (TOB) 21X or 18X is billed with occurrence code 22, the date associated with the occurrence code is equal to the through date of the claim and the patient status code is not 30.
SOA2f 1231 [Pattern 1231] Point of origin for admission is missing or invalid. This inpatient edit will set when a claim is submitted without a Point of Origin code, or the Point of Origin code is invalid.
TCRf 412 [Pattern 412] A therapy code has been submitted with inappropriate therapy revenue code. This outpatient edit will set when an inappropriate speech therapy revenue code is used for a therapy code submitted
TCRf 413 [Pattern 413] A therapy code has been submitted with inappropriate therapy revenue code. This outpatient edit will set when an inappropriate physical therapy revenue code is used for a therapy code submitted
TCRf 414 [Pattern 414] A therapy code has been submitted with inappropriate therapy revenue code. This outpatient edit will set when an inappropriate occupational therapy revenue code is used for a therapy code submitted
TCRf 3991 [Pattern 3991] A therapy code has been submitted with inappropriate therapy revenue code. This outpatient edit will set when 92521-92524 is used and revenue code 0440-0444 or 0449 is not used
TFEf 21541 [Pattern 21541] The statement covers period through date of service <1> is past the Medicare institutional timely filing limit. This outpatient edit will set when the claim through date hits or exceeds the timely filing limit.
THMOf 28354 [Pattern 28354] For claim lines billing therapy assistant services modifier CQ must be submitted with modifier GP and modifier CO must be submitted with modifier GO. This outpatient edit will set when therapy assistant services are billed and CQ and GP are not sent together or CO and GO modifiers are not sent together.
THSf 19670 [Pattern 19670] Procedure code <1> is a telehealth service and must be billed with revenue code 0780 for Rural Health Clinic claims. This outpatient edit will set when a telehealth service code is not paired with revenue code 0780 for rural health clinic claims
THSf 22650 [Pattern 22650] Procedure code <1> is a telehealth service and must be billed with revenue code 0780 for outpatient hospital claims. This outpatient edit will set when a telehealth service code is not paired with revenue code 0780 for outpatient hospital claims
TMCEf 4242 [Pattern 4242] Therapy evaluation and reevaluation procedure code requires a therapy service modifier. This outpatient edit will set when a Physical therapy evaluation code is used, and GP modifier is not used
TMCEf 4243 [Pattern 4243] Therapy evaluation and reevaluation procedure code requires a therapy service modifier. This outpatient edit will set when a occupational therapy evaluation code is used and GO modifier is not used
TMCEf 4244 [Pattern 4244] Therapy evaluation and reevaluation procedure code requires a therapy service modifier. This outpatient edit will set when a speech therapy evaluation code is used and GN modifier is not used
TOAf 20742 [Pattern 20742] This claim has an invalid type of admission code. This outpatient edit will set when the type of admission code is Invalid.
TOAf 20743 [Pattern 20743] This claim has a missing type of admission code. This outpatient and inpatient edit will set when the type of admission code is missing.
TOAf 20789 [Pattern 20789] This claim has an invalid type of admission code <1>. This inpatient edit will set when the type of admission code is invalid.
TOAFf 23256 [Pattern 23256] Type of Admission Code 4 for Newborn cannot be billed more than once in a lifetime. This outpatient and inpatient edit will set when the type of admission code of 4 is billed more than once.
TOBf 5098 [Pattern 5098] The type of bill code is invalid. This outpatient edit will set when the type of bill is invalid.
TOBf 5362 [Pattern 5362] The type of bill code is invalid or missing. This outpatient edit will set when the type of bill is invalid or missing.
TOBf 5364 [Pattern 5364] The type of bill code is invalid or missing. This inpatient edit will set when a claim is submitted with a Type of Bill that is invalid or missing.
TOBf 22814 [Pattern 22814] The type of bill code is invalid. This inpatient edit will set when a claim is submitted with a Type of Bill that is invalid.
TOBQf 22659 [Pattern 22659] Bill types with a frequency code of Q, can only be billed after the normal timely filing parameters have expired. This inpatient and outpatient edit will set when an XXQ TOB claim was billed after the normal timely filing parameters have expired.
TRCf 160 [Pattern 160] A therapy service revenue code requires a therapy service modifier. This outpatient edit will set when revenue code: 042x is used and GP modifier is not used, revenue code 043x is used and GO modifier is not used, or 044x is used and GN modifier is not used.
TSMf 161 [Pattern 161] Therapy service modifier requires therapy service revenue code. This outpatient edit will set when therapy type of bill 012X, 013X, 022X, 023X, 074X, 075X, 085X is used and Therapy service modifiers (GP, GO and GN) are not.
TTOBf 30350 [Pattern 30350] Procedure code <1> for the telehealth site origination facility fee cannot be billed on type of bill <1> . This outpatient edit will set when procedure code Q3014 is used and type of bill 012X, 013X, 022X, 023X, 071X, 072X, 073X, 076X, 077X, and 085X is not used.
UNLf Noridian0002A [DDR Noridian0002A] When an unlisted procedure code is billed a corresponding description of that procedure is required. This outpatient edit will set when an unlisted procedure code is billed with no procedure code description.
VALf 7602 [Pattern 7602] This claim has an invalid value code This outpatient edit will set when an invalid value code is billed.
VALf 17456 [Pattern 17456] This claim has an invalid value code <1>. This inpatient edit will set when a claim is submitted with an invalid Value Code.
VCCCf 21839 [Pattern 21839] Value code 42 and condition code 26 must both be present on the claim This inpatient edit will set when a claim is billed with a Condition Code 26 and not a Value Code 42 -or- An inpatient claim is billed with a Value Code 42 and not a Condition Code 26.
VCD5f 19261 [Pattern 19261] Value code D5 is required on TOB 072X ESRD claims This outpatient edit will set when the type of bill is 072X and the D5 value code is not on the claim.
VCDf 1235 [Pattern 1235] Value code default of 99.99 cannot be reported on code J0882 or Q4081. This outpatient edit will set when value code amount equals 99.99 and HCPC J0882 or Q4081 is used.
VCHf 497 [Pattern 497] An appropriate value code is required for HCPCS codes Q4081 or J0882. This outpatient edit will set when HCPCS Q4081 or J0882 is used and value code 48 and 49 are not located on the claim.
VRCf 524 [Pattern 524] Vaccine HCPCS codes require an appropriate revenue code. This outpatient edit will set when a vaccine HCPC is billed, and the appropriate rev code is not used.
VRCf 2138 [Pattern 2138] Vaccine HCPCS codes require an appropriate revenue code. This outpatient edit will set when a vaccine HCPC is billed, and the appropriate rev code is not used.