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Part B 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.

Note: For diagnosis related NCE editing, please ensure the appropriate Diagnosis Code Reference Number required for payment is appended to the service line. For example, if you submit a claim for an influenza virus vaccination, use the Diagnosis Code Reference Number for Z23 in the 2400 loop SV107 segment for the line item.

NCE Flag NCE Rule ID NCE Message NCE Description
BAG 20080 (Pattern 20080) Procedure code has not met the associated Age relationship criteria for CMS ID per LCD or NCD guidelines. The edit will set when the associated age relationship criteria is not met per the LCD.
BDS 4543 (Pattern 4543) The beginning or ending Date of Service (DOS) is invalid or missing. This edit will set when any of the following statements are true:
the beginning or ending date of service is empty OR
the beginning or ending date of service is greater than the entry date OR
the patient date of birth is greater than the beginning date of service OR
the beginning date of service is greater than the ending date of service OR
the beginning date of service = 1/1/1970
BPO 20080 (Pattern 20080) Procedure code has not met the associated Place of Service relationship criteria for CMS ID per LCD or NCD guidelines. The edit will set when the associated place of service relationship criteria is not met per the NCD/LCD.
BPS 8195 (Pattern 8195) The place of service is missing or invalid. This edit reject claims when the place of service is not a valid place of service code for Medicare or is not effective for the date of service. Providers may resubmit with a valid place of service code.
CDL 4713 (Pattern 4713) Procedure code is expired. This edit will set when the procedure code is no longer an effective Medicare code. Providers may resubmit with a procedure code that is effective for their date of service.
CPO 118 (Pattern 118) Only one individual may report a single care plan oversight CPT code per patient in the same month. Care Plan Oversight (CPO) services G0181 or G0182 may only be billed once per calendar months. Providers may refer to Medicare Claims Process Manual, Internet Only Manual (IOM) 100-04, Chapter 12, Section 180 for further information.
DCP SmartEdit Smart Edit DCP: This line is a possible duplicate of a claim performed by the same provider on the same day. If you feel you have received this message in error or if you need to resubmit the claim without making any changes, please resubmit your claim on the next business day. This edit will set when a claim is submitted twice during a 10-hour period and no changes have been detected.
DOB 4542 (Pattern 4542) Patient's date of birth is missing or invalid. This edit will set when the patient's date of birth is empty. Providers may resubmit with a valid date of birth in item 3 of the CMS-1500 claim form or its electronic equivalent.
DTU 20573 (Pattern 20573) Discrepancy detected between the number of units on this claim line and the difference between the beginning date of service and the ending date of service. This edit will set when the procedure code date of service is spanned and the submitted units does not equal the number of days included in the date of service to and from dates.
FCRP 7785 (Pattern 7785) Informational - Procedure code is a facility service code. This service is not to be reported on a professional claim. This edit will return an informational message when the procedure code is G0378-G0384 or G0463.
FCRP 23763 (Pattern 23763) Informational - Procedure code is a facility service code. This service is not to be reported on a professional claim. This edit will return an informational message when the procedure code is G0071 billed with G0466-G0470 or the procedure code is G0511, G0512 or G2025.
IAG 4564 (Pattern 4564) Diagnosis code or codes is not typical for age. This edit will set when the diagnosis code is not typical for the patient's age.
IAGa 28165 (Pattern 28165) Diagnosis is not typical for age. This edit will set when any of the following statements are true:
the place of service is 24 AND
the ICD-10 diagnosis age is for newborns and the patient's age is greater than 0 OR
the ICD-10 diagnosis age is for adolescents and the patient's age is greater than 17 OR
the ICD-10 diagnosis age is for maternity and the patient's age is less than 9 or greater than 64 OR
the ICD-10 diagnosis age is for adults and the patient's age is less than 15
ICD 8400 (Pattern 8400) The diagnosis code or codes are invalid. This edit will set when a claim line has one or more invalid diagnosis codes. Providers may submit with an updated diagnosis in item 21 of the CMS-1500 claim form or its electronic equivalent.
ICM 4516 (Pattern 4516) There is no primary diagnosis listed for this procedure. This edit will set when the primary diagnosis is empty. Providers may resubmit with a diagnosis pointer in item 24E of the CMS-1500 claim form or its electronic equivalent
IDL 4519 (Pattern 4519) Diagnosis code has been deleted. This edit will set when the diagnosis terminated for the date of service. Providers may submit with an updated diagnosis in item 21 of the CMS-1500 claim form or its electronic equivalent.
IDUP 26246 (Pattern 26246) Diagnosis code or codes may only be reported once per claim line. This edit will set when diagnosis codes appear more than once on a claim line. Providers may resubmit with the duplicate diagnosis removed.
IDX 4595 (Pattern 4595) Additional digits are required for nonspecific diagnosis code or codes. This edit will set when a diagnosis code is specified in the system as a non-specific/incomplete diagnosis code.
IMC 4006 (Pattern 4006) Modifiers cannot be submitted on the same claim line. This edit will set when the modifier combinations are inappropriate when submitted together on the same claim line.
IMO 13248 (Pattern 13248) The modifier code or codes are invalid. This edit will set when one or more invalid modifier codes are submitted. Providers may resubmit with an updated diagnosis in item 24E of the CMS-1500 claim form.
ISX 157 (Pattern 157) Diagnosis code(s) typically would not be reported for a patient whose gender is male/female. This edit will set when the diagnosis code describes a condition for a specific gender and the patient's gender does not match and an appropriate modifier is not present (i.e., hysterectomy diagnosis and patient is male)
ISXa 677 (Pattern 677) Diagnosis not typical for patient gender. This edit will set when the Place of Service (POS) is 24 and the provider specialty is 49 and the diagnosis code does not match the patient gender and an appropriate modifier is not present.
mAM 8196 (Pattern 8196) HCPCS code is identified as an ambulance code and requires an ambulance modifier appended per CMS guidelines. This edit will set when an ambulance procedure code is submitted without an origin and destination modifier.
mANM 19482 (Pattern 19482) Anesthesia code on claim Line ID requires an appropriate modifier per Medicare guidelines. This edit will set when an anesthesia procedure code is submitted without an appropriate anesthesia modifier present.
Resources:
JEB Modifiers
JFB Modifiers
mAS 54 (Pattern 54) A statutory payment restriction for assistants at surgery applies to procedure code per Medicare guidelines. This edit will set when modifier 80, 81, 82 or AS are submitted for a procedure code with a 1 (Assistant at surgery may not be paid) in the ASST field on the Medicare Physician Fee Schedule.
mAT 93 (Pattern 93) Per Medicare guidelines procedure code requires modifier GP, GO or GN. If you feel you have received this message in error, please resubmit the claim with your taxonomy code. This edit will set when the procedure code is an 'always therapy' code and modifier GN, GO or GP is not present.
mAWF 2833 (Pattern 2833) This service is covered once in a lifetime per Medicare guidelines. If you feel you have received this message in error or are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when the procedure code is G0438 billed more than once for the same beneficiary.
mAWP 2834 (Pattern 2834) Service occurred within a year of an initial preventive physical exam. This edit will set when procedure code G0438 or G0439 is billed within 12 months of G0402 for the same patient. For more information, please see Internet Only Manual (IOM) Publication 100-04 Medicare Claims Processing Manual, Chapter 18 section 140.6-140.7.
mAWS 27261 (Pattern 27261) Service occurred within a year of last covered annual wellness visit. This edit will set when procedure code G0439 is billed within 12 months of G0438 or G0439 for the same patient. For more information, please see Internet Only Manual (IOM) Publication 100-04 Medicare Claims Processing Manual, Chapter 18 section 140.6-140.7.
mB2 4428 (Pattern 4428) Per Medicare guidelines, the usual payment adjustment for bilateral procedures does not apply. Base payment for each side on the lower of the actual charge for each side or 100% of the fee schedule amount for each side. This edit will set when the BILAT indicator is 0, 2 or 3 on the Medicare Physician Fee Schedule and modifier 50 is present
mB50 26765 (Pattern 26765) A bilateral procedure code submitted with modifier 50 and billed with more than 1 unit of service is inappropriate. Bilateral procedures billed with a modifier 50 should be billed with one unit of service per Medicare guidelines. This edit will set when modifier 50 is submitted for a procedure code with a 1 or 3 in the BILAT field on the Medicare Physician Fee Schedule (DB screen) and the submitted unit are greater than 1
mCO 52 (Pattern 52) Billing for co-surgeons is not permitted for this procedure code per Medicare guidelines. The edit will set when modifier 62 is submitted for a procedure code with a 0 (Co Surgeons Not Permitted for This Procedure) in the COSURG field on the Medicare Physician Fee Schedule (DB screen)
mDP 20809 (Pattern 20809) Procedure code is within the global period of procedure code performed on history date of service by the same provider. The diagnosis indicates it is not for the same condition. Please review to determine if a modifier is appropriate. This edit will set when an E/M code is submitted during the post-op global period of a surgery with a different diagnosis code and the E/M does not contain an appropriate Modifier. Resource: CMS' Global Surgery Booklet
mDT 92 (Pattern 92) Procedure code describes a diagnostic procedure that requires a professional component modifier in POS per Medicare guidelines. This edit will set when the PC/TC indicator is 1 on the Medicare Physician Fee Schedule, the service is performed in an inpatient or outpatient facility place of service and modifier 26 is not present.
mEM 8300 (Pattern 8300) E/M code should not be billed without an appropriate modifier on the same day of a minor procedure or the same day or day before a major procedure. This edit will set when an E/M code is billed on the same day of a minor surgical procedure, or the same day or day before a major surgery and does not contain an appropriate modifier. Resource: CMS' Global Surgery Booklet
mFL 11622 (Pattern 11622) A diagnosis code or codes which meets medical necessity for procedure code is missing or invalid per Medicare guidelines. Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. This edit will set when the procedure code is for an Influenza vaccine or administration code and the appropriate diagnosis is not present.
mFOM 27186 (Pattern 27186) It is inappropriate to report modifier for a procedure that is discontinued on a professional claim per Medicare guidelines. This modifier is used by the facility to indicate that a procedure was terminated. This edit will set when modifiers 73 or 74 are present and the billing provider specialty is not 49.
mFP24 193 (Pattern 193) Per Medicare guidelines E/M code was submitted without an appropriate modifier and is within the global period of procedure code found in history on claim ID line ID with the same diagnosis code billed by the same provider as the current line provider. Please review to determine if a modifier is appropriate. This edit will set on claim lines that contain an E/M code submitted without a modifier 24 within the global period of a prior service which has a 10- or 90-day global period with the same diagnosis code and for the same provider. Providers may refer to their rejection report for the surgery's date of service. If applicable the appropriate global modifier may be appended. Please see: CMS' Global Surgery Booklet for further details.
mFR 17334 (Pattern 17334) The frequency does not meet policy requirements for the procedure code per Medicare guidelines. This edit will set when the procedure code is 76706 and the code has been reported more than once per lifetime.
mFR 28692 (Pattern 28692) The frequency does not meet policy requirements for the procedure code per Medicare guidelines. This edit will set when the procedure code is 82947 or 82950, modifier TS is present, and the code has been billed more than once every six months.
mFR 30005 (Pattern 30005) The frequency does not meet policy requirements for the procedure code per Medicare guidelines. This edit will set when the procedure code is G0472, the patient DOB is 1/1/1945 - 12/31/1965 and the code is billed more than once per lifetime.
mFR 30246 (Pattern 30246) The frequency does not meet policy requirements for the procedure code per Medicare guidelines. This edit will set when the procedure code is 71271 and the code is billed more than once annually.
mFR 28693 (Pattern 28693) Per Medicare guidelines the frequency does not meet policy requirements for the procedure code. This edit will set when the procedure code is 82947, 82950 or 82951, modifier TS is not present, and the code has been billed more than once every twelve months.
mFR 26876 (Pattern 26876) Per Medicare guidelines the frequency does not meet policy requirements for the procedure code. This edit will set when the procedure code is G0402, and the code has been reported more than once per lifetime.
MFX1 7011 (Pattern 7011) The maximum frequency for the procedure code has been exceeded. The allowable maximum frequency for the procedure is 1 time per calendar month. This edit will set when the procedure code is 99487, 99490 or 99491 and the code is billed more than once in a calendar month.
mGS 28261 (Pattern 28261) Procedure code has been reported without the appropriate screening diagnosis code per Medicare guidelines. Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. If you are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when the procedure code G0117 or G0118 are submitted without an appropriate diagnosis code.
mGT 31 (Pattern 31) Modifier 26, TC is inappropriately appended to procedure code per Medicare guidelines. This edit will set when modifier 26 or TC is submitted for a procedure code with a 4 (Global Test Only Code) in the PC/TC field on the Medicare Physician Fee Schedule
mHB 11625 (Pattern 11625) A diagnosis code or codes which meets medical necessity for procedure code is missing or invalid per Medicare guidelines. Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. This edit will set when the procedure code is for a Hepatitis B vaccine or administration and the appropriate diagnosis is not present.
mHCS 30172 (Pattern 30172) HCPCS code G0472 is not a covered service when submitted without an appropriate diagnosis code for a Medicare beneficiary born prior to 1945 or after 1965 per Medicare guidelines. Please verify the correct date of birth and diagnosis were submitted on the claim and ensure the appropriate diagnosis code reference number required for payment is appended to the service line. If you are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when the procedure code is G0472, the patient DOB is 1/1/1945 - 12/31/1965 and the appropriate diagnosis code is not submitted.
mI9 4282 (Pattern 4282) ICD-9 codes cannot be billed with dates of service greater than September 30, 2015, per CMS guidelines. This edit will set when an ICD-9 code is submitted and the beginning date of service is greater than 9/30/2015.
mIC 4616 (Pattern 4616) Procedure code is a service covered incident to a physician's service and modifier 26 or TC is not appropriate per Medicare guidelines. If you are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when the procedure code has a PC/TC indicator of 5 on the Medicare Physician Fee Schedule and modifier 26 or TC are present.
mIM 3474 (Pattern 3474) Modifier 62 is not appropriate for procedure code per Medicare guidelines. This edit will set when modifier 62 is submitted for a procedure code with a 9 (Concept Does Not Apply) in the COSURG field on the Medicare Physician Fee Schedule
mIM 26410 (Pattern 26410) Modifier 26, TC is not appropriate for procedure code per Medicare guidelines. This edit will set when modifier 26 or TC is submitted for a procedure code with a 9 (Concept Does Not Apply) in the PC/TC field on the Medicare Physician Fee Schedule
mIM 26411 (Pattern 26411) Modifier is not appropriate for procedure code per Medicare guidelines. This edit will set when modifier 22 is present and the procedure code has Global Days of MMM, XXX or ZZZ on the Medicare Physician Fee Schedule.
mIM 26414 (Pattern 26414) Modifier 80, 81, 82, AS is not appropriate for procedure code per Medicare guidelines. This edit will set when modifier 80, 81, 82 or AS is submitted for a procedure code with a 9 (Concept Does Not Apply) in the ASST field on the Medicare Physician Fee Schedule
mIN 58 (Pattern 58) The current procedure code is considered a bundled service per Medicare guidelines. This edit will set when the procedure code has a STATUS indicator of T (only paid if no other physician service is billed on the same day) on the Medicare Physician Fee Schedule and a claim in history with a procedure code that has a STATUS of A (active) on the Medicare Physician Fee Schedule billed on the same date of service.
mIVA 50066 (Pattern 50066) Per Medicare guidelines, administration code billed for vaccine code is not appropriate. This edit will reject administration code 90471 or 90472 billed with Influenza, Pneumonia or Hepatitis-B vaccines. Resource: Internet Only manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 18, section 10.2.1
mMFL 3930 (Pattern 3930) The associated vaccine code for administration procedure code is missing or invalid per Medicare guidelines. This edit will set when an Influenza administration procedure code is billed and there is no influenza vaccine present in history.
mMHB 11463 (Pattern 11463) The associated vaccine code for administration procedure code is missing or invalid per Medicare guidelines. This edit will set when a Hepatitis B administration procedure code is billed and there is no Hepatitis B vaccine present in history.
mMPN 11461 (Pattern 11461) The associated vaccine code for administration procedure code is missing or invalid per Medicare guidelines. This edit will set when a Pneumococcal administration procedure code is billed and there is no Pneumococcal vaccine present in history.
mMSP 120 (Pattern 120) Per Medicare guidelines the diagnosis code(s) billed does not support the medical necessity of G0101. This edit will set when the procedure code is G0101, and the appropriate diagnosis is not submitted.
mMUR 20872 (Pattern 20872) HCPCS code R0075 was billed without the required UN UP UQ UR or US modifier. This edit will set when the procedure code is R0075 and modifiers UN, UP, UQ, UR or US are not present.
mNP 4618 (Pattern 4618) Procedure code does not typically require performance by a physician in place of service per Medicare guidelines. If you feel you have received this in error or are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when the procedure code has a PC/TC indicator of 5 on the Medicare Physician Fee Schedule and the service is performed in an inpatient or outpatient facility setting.
MOD50a 1108 (Pattern 1108) Modifier 50 is not recognized when billed by an Ambulatory Surgical Center (ASC). Please ensure the appropriate taxonomy code is submitted. This edit will set when the place of service is 24, billing provider specialty is 49 and modifier 50 is present.
mONP 23955 (Pattern 23955) Per Medicare CPT or HCPCS code must have modifier GN. This edit will set when the procedure code is for speech therapy only and the billing provider specialty is 15 and modifier GN is not present.
mONP 24110 (Pattern 24110) Per Medicare CPT or HCPCS code must have modifier GO. This edit will set when the procedure code is for occupational therapy only and the billing provider specialty is 67 and modifier GO is not present.
mONP 24111 (Pattern 24111) Per Medicare CPT or HCPCS code must have modifier GP. This edit will set when the procedure code is for physical therapy only and the billing provider specialty is 65 and modifier GP is not present.
mPC 78 (Pattern 78) Procedure code describes the physician work portion of a diagnostic test. Modifier 26 or TC on current line ID is not appropriate per Medicare guidelines. This edit will set when modifier 26 or TC is submitted for a procedure code with a 2 (Professional Only Code) in the PC/TC field on the Medicare Physician Fee Schedule (DB screen)
mPDP 3590 (Pattern 3590) The PD modifier must be billed with the 26 modifiers. This edit will set when the procedure code has a PC/TC indicator of 1 on the Medicare Physician Fee Schedule modifier PD is present but modifier 26 is not present.
mPDT 3589 (Pattern 3589) The PD modifier may not be billed with the TC modifier. This edit will set when modifier PD and TC are both present on the claim line.
mPI 100 (Pattern 100) Procedure code describes a physician interpretation for this service and is inappropriate in this POS per Medicare guidelines. If you feel you have received this in error or are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when the procedure code has a PC/TC indicator of 8 on the Medicare Physician Fee Schedule and is submitted in an inappropriate place of service.
mPN 11623 (Pattern 11623) A diagnosis code or codes which meets medical necessity for procedure code is missing or invalid per Medicare guidelines. Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. This edit will set when the procedure code is for a Pneumococcal vaccine or administration and the appropriate diagnosis code is not present.
mPS 79 (Pattern 79) Procedure code describes the physician service. Use of modifier 26 or TC is not appropriate per Medicare guidelines. This edit will set when modifier 26 or TC is submitted for a procedure code with a 0 (Physician Service Code) in the PC/TC field on the Medicare Physician Fee Schedule.
mSB 15775 (Pattern 15775) Add-on procedure code has been submitted without an appropriate primary procedure code. If you feel you have received this in error or are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when an add-on procedure code is the only procedure reported by a physician without the appropriate primary procedure code.
mSP 8632 (Pattern 8632) Procedure code is within the global period of procedure code performed on history date of service by the same provider. Review documentation to determine if a modifier is appropriate. This edit will set when a surgical procedure with a global period of 000, 010 or 090 is billed within the global period of another surgery and does not contain an appropriate modifier. Resource: CMS' Global Surgery Booklet CMS' Global Surgery Booklet
mTC 77 (Pattern 77) Procedure code describes only the technical portion of a service or diagnostic test. Modifier 26 or TC is not appropriate per Medicare guidelines. This edit will set when the procedure code has a PC/TC indicator or 3 on the Medicare Physician Fee Schedule and modifier 26 or TC is present.
mTCH 26065 (Pattern 26065) Procedure code describes a diagnostic procedure that is not eligible for separate reimbursement in place of service per Medicare guidelines. If you feel you have received this in error or are seeking a denial or remittance advice, simply resubmit the claim. This edit will set when the PC/TC indicator is 3 on the Medicare Physician Fee Schedule and the service is performed in an inpatient or outpatient facility place of service.
mTF 20657 (Pattern 20657) The beginning date of service occurred more than 12 months from the claim submission date which exceeds Medicare timely filing guidelines. For more information, please visit the JEB Timely Filing webpage or the JFB Timely Filing webpage. This edit will set when the current claim line's beginning date of service is more than 12 months from the claim's entry submission date and the 2300 and/or 2400 note segment is empty.
The edit will be bypassed when the following conditions are met:
-the 2300 and/or 2400 note segment is not empty; OR
-the DOS is on or after 3/1/20 and the procedure code is A0425, A0427 or A0429 with modifier CR
mTS 45 (Pattern 45) Team surgery is not permitted for this procedure code per Medicare guidelines. The edit will set when modifier 66 is submitted for a code with a 0 (Team Surgeons not Permitted for This Procedure) in the TEAMSURG field on the Medicare Physician Fee Schedule
MUEa 33897 (Pattern 33897) The units of service billed for procedure code exceed the number of units allowed per day per Medicare Medically Unlikely Edits. This edit will reject ASC facility services when the unit of service exceeds the MUE value, and the service is not subject to bilateral billing. For more information on Medically Unlikely Edits, please visit CMS Medically Unlikely Edits webpage.
mUN 24078 (Pattern 24078) Per Medicare CCI guidelines procedure code has an unbundle relationship with history procedure code online ID and claim ID. This edit will set if the procedure code on the current line and any other procedure code billed for the same patient on the same day by the same provider can't be billed together. Providers may refer to their rejection report for the primary procedure. Medicare's National Correct Coding Initiative (NCCI) page will contain further information.
n019L Noridian0037b (DDR Noridian0037b) A diagnosis code or codes which meets medical necessity for procedure code is missing or invalid per NCD 190.11 guidelines. This edit will reject claims when a covered diagnosis is not submitted for NCD 190.11 Home PT INR Monitoring Anticoagulation. Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. For more information, visit: LCD or NCD Coverage Indications and Limitations
n024L Noridian0043b (DDR Noridian0043b) A diagnosis code or codes which meets medical necessity for procedure code is missing or invalid per NCD 210.1 guidelines. This edit will reject claims when a covered diagnosis is not submitted for NCD 210.1 Prostate Cancer Screening Tests.  Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. For more information, visit LCD or NCD Coverage Indications and Limitations
n043L Noridian0046b (DDR Noridian0046b) A diagnosis code or codes which meets medical necessity for procedure code is missing or invalid per NCD 190.1 guidelines. This edit will reject claims when a covered diagnosis is not submitted for NCD 190.1 Histocompatibility Testing. Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. For more information, visit: LCD or NCD Coverage Indications and Limitations
n196A Noridian0006 (DDR Noridian) The associated vaccine code for administration procedure code is missing or invalid per Medicare guidelines. This edit will set when administration code 90471 or 90472 is billed without an appropriate vaccine code in history.
n362Dmod Noridian0002 (DDR Noridian0002) Modifiers 76, 78 and 79 are not valid for Evaluation and Management codes per Medicare guidelines. This edit will set when the procedure code is 99201-99499 except 99292 and modifier 76, 78 or 79 is present.
nATkx Noridian0032b (DDR Noridian0032b) 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 edit will return an informational message when a therapy code is billed with modifier KX.
nB2 Noridian0004 (DDR Noridian0004) The usual payment adjustment for bilateral procedures does not apply. The procedure code is inconsistent with the modifier used per Medicare guidelines. This edit will set when the BILAT indicator is a 9 on the Medicare Physician Fee Schedule and modifier 50 is present.
nLDCT Noridian0016b (DDR Noridian0016b) A diagnosis code or codes which meets medical necessity for procedure code is missing or invalid per NCD 210.14 guidelines. This edit will reject claims when a covered diagnosis is not submitted for NCD 210.14 Lung Cancer Screening Coverage. Please ensure the appropriate diagnosis code reference number required for payment is appended to the service line. For more information, visit: LCD or NCD Coverage Indications and Limitations
nMOD99 Noridian0017b (DDR Noridian0017b) When using modifier 99 it is inappropriate to append other modifiers in item 24D. This edit will set when modifier 99 is appended with other modifiers in item 24D or electronic equivalent (Loop 2400 SV101 Segment). For more information on correct use of modifier 99, please visit the JEB Modifier 99 webpage or the JFB Modifier 99 webpage.
nMOD99i Noridian0023b [DDR Noridian0023b] Reminder - Modifier 99 should only be appended when five or more modifiers are applicable to the service line. If you are appending modifier 99 with four or less modifiers, please discontinue using modifier 99. This edit will return an informational message when modifier 99 is present in the first position, there are no other modifiers on the claim and there are claim notes present. For more information on correct use of modifier 99, please visit the JEB Modifier 99 webpage or the JFB Modifier 99 webpage.
nMOD99m Noridian0022b (DDR Noridian0020b) When submitted modifier 99 all modifiers involved must be included in item 19 narrative or electronic equivalent. This edit will set when modifier 99 is submitted alone and there are no modifiers reflected in item 19 narrative or electronic equivalent (Loop 2300 or 2400, Segment NTE or SV101-7). For more information on correct use of modifier 99, please visit the JEB Modifier 99 webpage or the JFB Modifier 99 webpage.
nMODsplit Noridian0011b (DDR Noridian0011b) Informational - Noridian encourages providers submit separate claims to split services billed with the KX modifier from other services not billed with this modifier. This helps reduce delays in claims processing. This edit will return an informational message when some claim lines contain modifier KX, and some lines do not.
nMolDX Noridian0007 (DDR Noridian0007) A DEX Z-Code identifier is required when the procedure code is billed. This edit will set when a MolDX procedure code is submitted, and the procedure description is blank.
nNE Noridian0047b (DDR Noridian0047b) Modifier PA PB or PC was submitted for procedure code. Please confirm the use of this modifier was intentional by resubmitting with a comment in the 2300 or 2400 NTE segment. If unintentional, please resubmit a corrected claim. This edit will reject claims when modifier PA, PB or PC is submitted.
nOTCfr Noridian0050b (DDR Noridian0050b) The procedure code exceeds the maximum frequency allowance of 8 in one month. This edit will set when an over-the-counter (OTC) COVID-19 test is billed more than 8 times per beneficiary in a calendar month.
PISa 1467 (Pattern 1467) Informational - Medicare does not pay separately for this service. This edit will return an informational message on ASC facility claims (place of service is 24, specialty code 49) when the procedure code is not separately payable and/or considered packaged for ASCs in accordance to CMS' ASC Payment Rates - Addenda.
POSa 639 (Pattern 639) Informational - Procedure code is not typically performed in an ASC setting. This edit will return an informational message on ASC facility claims (place of service is 24, specialty code 49) when the procedure code is not payable for ASCs in accordance with CMS' ASC Payment Rates - Addenda.
REF 20876 (Pattern 20876) The procedure code requires a referring physician. This edit will reject claims when the procedure code requires a referring or ordering provider and the referring/ordering provider information is not present in item 17 and 17B of the CMS-1500 claim for or its electronic equivalent
SIP 6248 (Pattern 6248) Informational - Sequential intravenous push code 96376 may only be reported by facilities. This service is not to be reported on a professional claim. This edit will return an informational message when the procedure code is 96376.
SMARTEDIT DUE TO AN ERROR THE CLAIM COULD NOT BE INSERTED This message is returned when invalid/incorrectly formatted data is submitted on the claim. An example of invalid data would be when an invalid birthdate of 00010101 Is submitted.