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 |
|---|---|---|---|
| 001ICM | 13316 | [Pattern 13316] The principal diagnosis code is either not a valid diagnosis or is invalid for the date of service on the claim. | This outpatient edit will set when the principal diagnosis code billed on the claim is either invalid or invalid for the date of service |
| 001ICM | 17398 | [Pattern 17398] The reason for visit diagnosis code is either not a valid diagnosis or is invalid for the date of service on the claim. | This outpatient edit will set when the reason for visit diagnosis code billed on the claim is either invalid or invalid for the date of service. |
| 001ICM | 17399 | [Pattern 17399] The other diagnosis code is either not a valid diagnosis or is invalid for the date of service on the claim. | This outpatient edit will set when one of the other diagnosis codes billed on the claim is invalid or invalid for the dates of service. |
| 001ICM | 17410 | [Pattern 17410] The principal diagnosis code requires an additional character for the dates of service on the claim. | This outpatient edit will set when the principal diagnosis code billed on the claim is incomplete for the dates of service. |
| 001ICM | 17423 | [Pattern 17423] The reason for visit diagnosis code requires an additional character for the dates of service on the claim. | This outpatient edit will set when the reason for visit diagnosis code billed on the claim is incomplete for the dates of service. |
| 001ICM | 17424 | [Pattern 17424] The other diagnosis code requires an additional character for the dates of service on the claim. | This outpatient edit will set when one of the other diagnosis codes billed on the claim is incomplete for the dates of service. |
| 002IAG | 27742 | [Pattern 27742] The principal diagnosis code is for maternity and is not typical for the patient age of 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 is for adolescents and is not typical for the patient's age 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 is for newborns and is not typical for the patient's age of 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 is for adolescents and is not typical for the patient's age of 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 | 17608 | [Pattern 17608] The principal diagnosis code is for adults and is not typical for the patient's age of 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 is for newborns and is not typical for the patient's age of 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 | 17616 | [Pattern 17616] The other diagnosis code is for adults and is not typical for the patient's age of 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 is for adolescents and is not typical for the patient's age of 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 is for adults and is not typical for the patient's age of 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 is for newborns and is not typical for the patient's age of 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 | 27741 | [Pattern 27741] The reason for visit diagnosis code is for maternity and is not typical for the patient's age of 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 is for maternity and is not typical for the patient's age of 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 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 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. |
| 003ISX | 18852 | [Pattern 18852] The reason for visit diagnosis code is designated for female patients only and this conflicts with the submitted gender of the patient. | This outpatient edit will set when the reason for visit diagnosis code on the claim is designated as female only, which conflicts with the submitted gender of the patient. |
| 003ISX | 18851 | [Pattern 18851] The reason for visit diagnosis code is designated for male patients only and this conflicts with the submitted gender of the patient. | This outpatient edit will set when the reason for visit diagnosis code on the claim is designated as male only, which conflicts with the submitted gender of the patient. |
| 003ISX | 6243 | [Pattern 6243] The principal diagnosis code is designated for male patients only and this conflicts with the submitted gender of the patient. | This outpatient edit will set when the principal diagnosis code on the claim is designated as male only, which conflicts with the submitted gender of the patient. |
| 003ISX | 6238 | [Pattern 6238] The principal diagnosis code is designated for female patients only and this conflicts with the submitted gender of the patient. | This outpatient edit will set when the principal diagnosis code on the claim is designated as female only, which conflicts with the submitted gender of the patient. |
| 008CSX | 6120 | [Pattern 6120] The HCPCS code includes a gender designation and the gender submitted on the claim does not match per CMS Integrated OCE (IOCE) specifications. | This outpatient edit will set when a submitted procedure or HCPCS code is not valid for the patient's gender on the claim. This edit will bypass if condition code 45 is present on the claim. |
| 00AGAC | 16780 | [Pattern 16780] The Admission diagnosis code 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 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 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 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 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 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. |
| 013NSP | 20073 | [Pattern 20073] Separate payment for procedure code is not provided by Medicare. | This outpatient edit will set when there is a HCPCS code on the claim with a status indicator of E2. The E2 indicates items and services not separately payable by Medicare. |
| 017IBP | 21830 | [Pattern 21830] The HCPCS code on this line was also billed on history claim on history line for the same date of service. This code is inherently bilateral and should not be billed more than once for the same date of service | This outpatient edit will set when an inherently bilateral procedure code (HCPC 92002, 92004, 92012, and 92104) is billed with more than one unit for the same date of service. This edit will not set with an XX7 or XX8 type of bill, 76 or 77 modifier, or G0 condition code is on the claim. |
| 017IBP | 7185 | [Pattern 7185] The HCPCS code on this line was also billed on history claim on history line for the same date of service. This code is inherently bilateral and should not be billed more than once for the same date of service | This outpatient edit will set when an inherently bilateral procedure code is billed with more than one unit for the same date of service. This edit will not set with an XX7 or XX8 type of bill, 76 or 77 modifier, or G0 condition code is on the claim. |
| 017IBP | 4478 | [Pattern 4478] The HCPCS code on this line was also billed on history claim on history line for the same date of service. This code is inherently bilateral and should not be billed more than once for the same date of service | This outpatient edit will set when an inherently bilateral procedure code (HCPC 92002, 92004, 92012, and 92104) is billed with more than one unit for the same date of service, the 76 or 77 modifier or G0 condition code are not the claim. |
| 017IBP | 4477 | [Pattern 4477] HCPCS code is inherently bilateral and should not be billed more than once for the same date of service. | This outpatient edit will set when HCPC 92002, 92004, 92012, or 92104 is used, the service units are greater than 1, and 76 or 77 modifier and G0 condition code are not the claim. |
| 018INP | 26265 | [Pattern 26265] Procedure code is designated as an inpatient only procedure performed in an outpatient hospital setting per CMS. | This outpatient edit will set when an inpatient only procedure is submitted on an outpatient claim, modifier CA is not present and there is not another claim line with a status indicator of T for the same day. |
| 018INP | 19032 | [Pattern 19032] Procedure code is designated as an inpatient only procedure performed in an outpatient hospital setting per CMS. | This outpatient edit will set when an inpatient only procedure is submitted on an outpatient claim, modifier CA is not present and there is not another claim line with a status indicator J1 or T. |
| 018INP | 18990 | [Pattern 18990] Procedure code is designated as an inpatient only procedure performed in an outpatient hospital setting per CMS. | This outpatient edit will set when an inpatient only procedure is submitted on an outpatient claim, modifier CA is not present and there is not another claim line with a status indicator J1 or T. |
| 018INP | 18988 | [Pattern 18988] Procedure code is designated as an inpatient only procedure performed in an outpatient hospital setting per CMS. | This outpatient edit will set when an inpatient only procedure is submitted on an outpatient claim, modifier CA is not present and there is not another claim line with a status indicator J1 or T. |
| 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 are invalid due to having an incomplete number of digits. | This inpatient edit will set when another diagnosis code has an incomplete number of digits. |
| 01ODIP | 20701 | [Pattern 20701] The other procedure code has an incomplete number of digits. | This inpatient edit will set when another procedure code has an incomplete number of digits. |
| 01OIP | 20700 | [Pattern 20700] The other procedure code is invalid. | This inpatient edit will set when another procedure code is invalid. |
| 01PDID | 20675 | [Pattern 20675] The principal diagnosis code is incomplete. | This inpatient edit will set when the principal diagnosis code is incomplete. |
| 01PDIP | 20698 | [Pattern 20698] The principal procedure code is incomplete. | This inpatient edit will set when the principal procedure code is incomplete. |
| 01PIP | 20689 | [Pattern 20689] The principal procedure code is invalid. | This inpatient edit will set when the principal procedure code is invalid. |
| 01PMD | 20673 | [Pattern 20673] The principal diagnosis code is missing on the claim. | This inpatient edit will set when the principal diagnosis code is missing on the claim. |
| 020CCP | 7376 | [Pattern 7376] Procedure code is considered to be a component of the comprehensive code on claim ID Line ID and this line should be denied. A modifier will not override this edit. | This outpatient edit will set when the procedure code billed is identified as part of another procedure code billed on the same day and use of a modifier is not appropriate. |
| 020CCP | 25650 | [Pattern 25650] Procedure code is considered to be a component of the comprehensive code on claim ID Line ID and this line should be denied. A modifier will not override this edit. | This outpatient edit will set on 85X bill types when the procedure code submitted is identified as part of another procedure code billed on the same date and use of a modifier is not appropriate. |
| 020CCP | 25629 | [Pattern 25629] Procedure code is considered to be a component of the comprehensive code on claim ID Line ID and this line should be denied. A modifier will not override this edit. | This outpatient edit will set on 85X bill types when the procedure code submitted is identified as part of another procedure code billed with the same date, on the same claim and use of a modifier is not appropriate. |
| 020CCP | 5253 | [Pattern 5253] Procedure code is considered to be a component of the comprehensive code on claim ID Line ID and this line should be denied. A modifier will not override this edit. | This outpatient edit will set when the procedure code submitted is identified as part of another procedure code billed with the same date and use of a modifier is not appropriate. |
| 020CCP | 25627 | [Pattern 25627] Procedure code is considered to be a component of the comprehensive code on claim ID Line ID and this line should be denied. A modifier will not override this edit. | This outpatient edit will set on 85X bill types with professional revenue codes when the procedure code submitted is identified as part of another procedure with the same date and the use of a modifier is not appropriate. |
| 020hCCP | 25632 | [Pattern 25632] History procedure code on history claim on history line is considered to be a component of the comprehensive procedure code on the current line and the history line may be denied. A modifier will not override this edit. | This outpatient edit will set on 85X bill types when the procedure code submitted is identified as part of another procedure billed with the same date and the use of a modifier is not appropriate. |
| 020hCCP | 5264 | [Pattern 5264] History procedure code on history claim on history line is considered to be a component of the comprehensive procedure code on the current line and the history line may be denied. A modifier will not override this edit. | This outpatient edit will set when the procedure code submitted is identified as part of another procedure code billed with the same date and the use of a modifier is not appropriate. |
| 021EMO | 33243 | [Pattern 33243] Medical visit is on the same day as a procedure with a status indicator of T or S without modifier 25 on claim. | This outpatient edit will set when one or more type T or S procedure codes occur on the same day as a line item containing an evaluation and management (E&M) code without modifier 25. |
| 021EMO | 33262 | [Pattern 33262] Medical visit is on the same day as a procedure with a status indicator of S without modifier 25 on claim. | This outpatient edit will set when one or more type S procedure codes occur on the same day as a line item containing an evaluation and management (E&M) code without modifier 25. |
| 021EMO | 33260 | [Pattern 33260] Medical visit is on the same day as a procedure with a status indicator of T or S without modifier 25 on claim. | This outpatient edit will set when one or more type T or S procedure codes occur on the same day as a line item containing an evaluation and management (E&M) code without modifier 25. |
| 022IMO | 4535 | [Pattern 4535] The modifier code is either not a valid code or not valid for the from date of service on the claim. | This outpatient edit will set when a modifier submitted is either not a valid code or not valid for the from date of service on the claim. |
| 023BDS | 4712 | [Pattern 4712] The service date is not within the From and Through dates of service on the claim. | This outpatient edit will set when the service date falls outside the range of the From and Through dates. |
| 027OIS | 23897 | [Pattern 23897] Only incidental services are billed on this claim. | This outpatient edit will set when a claim is submitted with only incidental services. |
| 027OIS | 26616 | [Pattern 26616 Only incidental services are billed on this claim. | This outpatient edit will set when a claim is submitted with only incidental services. |
| 028NRM | 26305 | [Pattern 26305] The HCPCS code on this line is not recognized by Medicare. An alternate code may be appropriate. | This outpatient edit will set when a claim line is submitted with codes that are not recognized by Medicare. An alternate code may be available. |
| 028NRM | 26326 | [Pattern 26326] The HCPCS code on this line is not recognized by Medicare. | This outpatient edit will set when a claim line is submitted with codes that are not recognized by Medicare. An alternate code may be available. |
| 03DDC | 4690 | [Pattern 4690] The other diagnoses code is a duplicate of the principal diagnosis code. | This inpatient edit will set when another 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 another diagnosis code is a duplicate to another other diagnosis code. |
| 040CCO | 25648 | [Pattern 25648] Procedure code is considered to be a component of the comprehensive code on the claim and this line should be denied. Review documentation to determine if a modifier is appropriate. | This outpatient edit will set when the procedure code is identified as a Column 2 code of a Column1/Column2 National Correct Coding Initiative (NCCI) edit code pair and the Column 1 code was billed for the same date of service and provider in the claims history. An appropriate modifier was not submitted. Resource: National Correct Coding Initiative (NCCI) | CMS |
| 040CCO | 7349 | [Pattern 7349] Procedure code is considered to be a component of the comprehensive code on the claim and this line should be denied. Review documentation to determine if a modifier is appropriate. | This outpatient edit will set when the procedure code is identified as a Column 2 code of a Column1/Column2 National Correct Coding Initiative (NCCI) edit code pair and the Column 1 code was billed for the same date of service and provider in the claims history. An appropriate modifier was not submitted. Resource: National Correct Coding Initiative (NCCI) | CMS |
| 040CCO | 25635 | [Pattern 25635] Procedure code is considered to be a component of the comprehensive code on the claim and this line should be denied. Review documentation to determine if a modifier is appropriate. | This outpatient edit will set when the procedure code is identified as a Column 2 code of a Column1/Column2 National Correct Coding Initiative (NCCI) edit code pair and the Column 1 code was also billed for the same date of service. An appropriate modifier was not submitted. Resource: National Correct Coding Initiative (NCCI) | CMS |
| 040CCO | 25636 | [Pattern 25636] Procedure code is considered to be a component of the comprehensive code on the claim and this line should be denied. Review documentation to determine if a modifier is appropriate. | This outpatient edit will set when the procedure code is identified as a Column 2 code of a Column1/Column2 National Correct Coding Initiative (NCCI) edit code pair and the Column 1 code was also billed for the same date of service. An appropriate modifier was not submitted. Resource: National Correct Coding Initiative (NCCI) | CMS |
| 040hCCO | 25634 | [Pattern 25634] History procedure code on a history claim is considered to be a component of the comprehensive code and the history line may be denied. Review the medical record to determine if an appropriate modifier should be assigned. | This outpatient edit will set when the procedure code is identified as a Column 2 code of a Column1/Column2 National Correct Coding Initiative (NCCI) edit code pair and the Column 1 code was billed for the same date of service and provider in the claims history. An appropriate modifier was not submitted. Resource: National Correct Coding Initiative (NCCI) | CMS |
| 040hCCO | 25633 | [Pattern 25633] History procedure code on a history claim is considered to be a component of the comprehensive code and the history line may be denied. Review the medical record to determine if an appropriate modifier should be assigned. | This outpatient edit will set on a Critical Access Hospital (CAH) claim with professional revenue codes (096x, 097x & 098x) when a procedure code billed is identified as part of a code pair and both were billed on the same date of service. An allowable modifier was not present. |
| 040hCCO | 4697 | [Pattern 4697] History procedure code on a history claim is considered to be a component of the comprehensive code and the history line may be denied. Review the medical record to determine if an appropriate modifier should be assigned. | This outpatient edit will set when the procedure code is identified as a Column 2 code of a Column1/Column2 National Correct Coding Initiative (NCCI) edit code pair and the Column 1 code was billed for the same date of service and provider in the claims history. An appropriate modifier was not submitted. Resource: National Correct Coding Initiative (NCCI) | CMS |
| 041IRC | 4731 | [Pattern 4731] Invalid or Missing Revenue Code | This outpatient edit will set when the revenue code is missing or invalid for the date of service. |
| 042MMV | 4514 | [Pattern 4514] Multiple medical visits on same day with the same revenue code and no condition code G0 is billed. | This outpatient edit will set when multiple medical visits are billed on the same date, with the same revenue code without condition code G0. |
| 042MMV | 4511 | [Pattern 4511] Multiple medical visits on same day with the same revenue code and no condition code G0 is billed. | This outpatient edit will set when multiple medical visits are billed on the same date, with the same revenue code without condition code G0. |
| 042MMV | 7156 | [Pattern 7156] Multiple medical visits on same day with the same revenue code and no condition code G0 is billed. E&M visit found on history claim. | This outpatient edit will set when multiple medical visits are billed on the same date, with the same revenue code without condition code G0. |
| 043TBP | 4515 | [Pattern 4515] Blood Administration code requires that a HCPCS Blood Product code be present on the claim. | This outpatient edit will set when a claim is submitted with a code for blood administration services, but no blood product code is present. |
| 044ORC | 4517 | [Pattern 4517] Observation room revenue code without specification of appropriate observation room service. | This outpatient edit will set when a claim contains an observation revenue code (0762) on a line with a non-observation HCPCS. |
| 048RRH | 4733 | [Pattern 4733] Claim line revenue code requires submission of a HCPCS code. | This outpatient edit will set when a revenue code is submitted with no HCPCS code, and one is required. |
| 049SIP | 6065 | [Pattern 6065] Ancillary service billed on the same day as an inpatient only procedure. | This outpatient edit will set when an inpatient only procedure is submitted on an outpatient claim. |
| 04AAGE | 16850 | [Pattern 16850] The Admission diagnosis 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 is not permissible for the patient's age. | This inpatient edit will set when another diagnosis is not permissible for the patients age. |
| 04PAGE | 7678 | [Pattern 7678] Age conflict; the Principal diagnosis 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. |
| 055NRS | 4518 | [Pattern 4518] Not reportable for this site of service. | This outpatient edit will set when a HCPCS code beginning with "C" is submitted on a type of bill other than 12X, 13X or 14X. |
| 05ADSX | 15922 | [Pattern 15922] The patient gender and Admission diagnosis code 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 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 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 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 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 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 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 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 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 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. |
| 062CNR | 18196 | [Pattern 18196] HCPCS code is not recognized by OPPS. | This outpatient edit will set when a claim line is submitted with a HCPCS code that is not recognized by the Outpatient Prospective Payment System (OPPS). |
| 062CNR | 4490 | [Pattern 4490] HCPCS code is not recognized by OPPS. An alternate code may be appropriate. | This outpatient edit will set when a claim line is submitted with a HCPCS code that is not recognized by the Outpatient Prospective Payment System (OPPS). An alternate HCPCS may be available. |
| 072SNB | 24066 | [Pattern 24066] Service is not billable to an FI or MAC. | This outpatient edit will set when a submitted HCPCS code has a status indicator of M. This edit will bypass when the submitted TOB is 85X and the revenue code is 096X, 097X or 098X. |
| 074UBP | 4653 | [Pattern 4653] Units greater than one for bilateral procedure billed with modifier 50. | This outpatient edit will set when a bilateral procedure is submitted with modifier 50 and the units on the line are greater than one. |
| 076TRC | 12878 | [Pattern 12878] A trauma response critical care code has been submitted without revenue code 068X and CPT code 99291. | This outpatient edit will set when trauma response critical care code G0390 is billed without revenue code 068X and CPT code 99291. |
| 087SSR | 3982 | [Pattern 3982] Skin substitute application procedure code <1> must be submitted with the appropriate skin substitute product procedure code on the same date of service. | This outpatient edit will set when a skin substitute application procedure code is submitted without a skin substitute product code. |
| 088PHC | 31957 | [Pattern 31957] A FQHC claim must contain a required FQHC payment code. | This outpatient edit will set when a Federally Qualified Health Clinic (FQHC) claim, bill type 77X, is billed without one of the required FQHC payment codes. |
| 089QVC | 30621 | [Pattern 30621] A FQHC claim requires both the FQHC payment code and a qualifying visit code. | This outpatient edit will set when bill type 77X is submitted with a required Federally Qualified Health Clinic (FQHC) payment code but an FQHC qualifying visit code is not present. |
| 089QVC | 30619 | [Pattern 30619] A FQHC claim requires both the FQHC payment code and a qualifying visit code. | This outpatient edit will set when bill type 77X is submitted with a required Federally Qualified Health Clinic (FQHC) payment code but an FQHC qualifying visit code is not present. |
| 089QVC | 30617 | [Pattern 30617] A FQHC claim requires both the FQHC payment code and a qualifying visit code. | This outpatient edit will set when bill type 77X is submitted with a required Federally Qualified Health Clinic (FQHC) payment code but an FQHC qualifying visit code is not present. |
| 089QVC | 30616 | [Pattern 30616] A FQHC claim requires both the FQHC payment code and a qualifying visit code. | This outpatient edit will set when bill type 77X is submitted with a required Federally Qualified Health Clinic (FQHC) payment code but an FQHC qualifying visit code is not present. |
| 089QVC | 5080 | [Pattern 5080] A FQHC claim requires both the FQHC payment code and a qualifying visit code. | This outpatient edit will set when bill type 77X is submitted with a required Federally Qualified Health Clinic (FQHC) payment code but an FQHC qualifying visit code is not present. |
| 089QVC | 30620 | [Pattern 30620] A FQHC claim requires both the FQHC payment code and a qualifying visit code. | This outpatient edit will set when bill type 77X is submitted with a required Federally Qualified Health Clinic (FQHC) payment code but an FQHC qualifying visit code is not present. |
| 08QAD | 20527 | [Pattern 20527] Principal diagnosis code 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 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. |
| 090REV | 30614 | [Pattern 30614] The FQHC payment code requires specific revenue codes. | This outpatient edit will set on a claim with bill type 77X when the appropriate revenue code (0519 or 0900) is not submitted with the FQHC procedure code billed. |
| 090REV | 30615 | [Pattern 30615] The FQHC payment code requires specific revenue codes. | This outpatient edit will set on a claim with bill type 77X when the appropriate revenue code (0519 or 052X) is not submitted with the FQHC procedure code billed. |
| 091NCS | 24077 | [Pattern 24077] Items or services are not covered under the FQHC PPS and RHC claims. | This outpatient edit will set when type of bill 0710-071Z is used and the adjusted procedure code is an excluded or non-covered service. |
| 091NCS | 30631 | [Pattern 30631] Items or services are not covered under the FQHC PPS and RHC claims. | This outpatient edit will set when revenue code 0290-0299 or 0540-0549 is used or an adjusted procedure code is an excluded or non-covered service on an FQHC claim. |
| 092DDP | 7418 | [Pattern 7418] A device-dependent procedure requires that a device HCPCS code be submitted on the same day. | This outpatient edit will set when a device dependent code and a device procedure code is not used on the same date of service. |
| 093CTP | 11994 | [Pattern 11994] The corneal tissue processing HCPCS code requires a corneal transplant procedure submitted on the same date of service. | This outpatient edit will set when adjusted procedure code V2785 is used and a corneal transplant procedure is not billed on the same date of service. |
| 098LRP | 16801 | [Pattern 16801] This claim contains a pass-through device code but lacks the required associated procedure. | This outpatient edit will set when a pass-through device code with a status indicator of H is used without an associated procedure for the same date of service. |
| 099LPP | 18055 | [Pattern 18055] This claim contains a pass-through or non-pass-through drug or biological HCPCS code, but lacks the associated payable procedure that must be submitted on the same claim. | This outpatient edit will set when a pass-through or non-pass-through drug or biological is on the claim without an associated payable procedure on the claim. |
| 09OUAD | 5443 | [Pattern 5443] Diagnosis code 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. |
| 102IMP | 26627 | [Pattern 26627] Modifier codes cannot be submitted on the same claim line. | This outpatient edit will set when 2 modifiers with conflicting meaning are reported together on the same claim line. |
| 104AIR | 20206 | [Pattern 20206] Rural Health Clinic (RHC) claim, bill type 071X contains a procedure code reported with Modifier CG that is not eligible for the RHC all-inclusive rate. | This outpatient edit will set when 71X type of bill is billed with a CG modifier and is not eligible for an RHC all-inclusive rate. |
| 106AOP | 28170 | [Pattern 28170] Add-on procedure code has been submitted without an appropriate primary procedure code. | This outpatient edit will set when the claim has an add-on procedure code and does not have a primary procedure code dated the same day or the day before in the history. |
| 106AOP | 28171 | [Pattern 28171] Add-on procedure code has been submitted without an appropriate primary procedure code. | This outpatient edit will set when the claim has an add-on procedure code and does not have a primary procedure code dated the same day or the day before in the history. |
| 106AOP | 28501 | [Pattern 28501] Add-on procedure code has been submitted without an appropriate primary procedure code. | This outpatient edit will set when the claim has a drug add-on procedure code and does not have a drug primary code and the claim ID is the same. |
| 106AOP | 29195 | [Pattern 29195] Add-on procedure code has been submitted with a primary procedure code that received a deny or review edit. | This outpatient edit will set when the claim has an add-on procedure code and does not have a primary procedure code dated the same day or the day before in the history, or the history claim has a service start date before the date of the current claim line. |
| 106AOP | 29197 | [Pattern 29197] Add-on procedure code has been submitted with a primary procedure code that received a deny or review edit. | This outpatient edit will set when the claim has an add-on procedure code and does not have a primary procedure code dated the same day or the day before in the history and the history claim has a non-profile flag. |
| 106AOP | 29198 | [Pattern 29198] Add-on procedure code has been submitted with a primary procedure code that received a deny or review edit. | This outpatient edit will set when the claim has a drug add-on procedure code but does not have a drug primary code dated the same day and the history claim has a non-profile flag. |
| 111BIB | 27148 | [Pattern 27148] A service submitted on the claim is considered bundled into the biological. | This outpatient edit will set when a line item submitted on the claim is considered bundled into the biological. |
| 114CSM | 30737 | [Pattern 30737] Procedure code is not allowed with modifier CS as it is not eligible for a coinsurance and deductible waiver. | This outpatient edit will set when an item or services is submitted with modifier CS and it is not eligible for a coinsurance and deductible waiver. |
| 115CLA | 31471 | [Pattern 31471] COVID-19 lab add-on procedure code Current adjusted procedure code has been submitted without an appropriate primary procedure code. | This outpatient edit will set when a COVID-19 lab add-on procedure code is submitted without the required primary procedure for the same date of service. |
| 117TCA | 32881 | [Pattern 32881] The charge amount for the procedure code must be equal to or greater than $1.01. | This outpatient edit will set when a token charge amount of less than $1.01 is submitted for a drug HCPCS with a status indicator of G or K. |
| 11ANCP | 21495 | [Pattern 21495] Procedure code 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 is noncovered when a designated diagnosis code(s) 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) 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 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 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 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 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 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. |
| 20USC | 34710 | [Pattern 34710] Diagnosis code is an unspecified diagnosis code. | This inpatient edit will set when an unspecified diagnosis is used as a primary or secondary diagnosis. |
| ATSf | 162 | [Pattern 162] Hospitals must always report a therapy modifier for "Always Therapy" procedure codes. | This outpatient edit will set when a claim line contains an "Always Therapy" code without a therapy modifier GP, GO or GN present. |
| AWVFf | 1029 | [Pattern 1029] This service is only covered once a lifetime per Medicare. | This outpatient edit will set when HCPCS code G0438 is reported more than once in a lifetime. |
| AWVIPf | 1070 | [Pattern 1070] Service occurred within a year of an initial preventive physical exam. | This outpatient edit will set when HCPCS code G0438 or G0439 is submitted and G0402 has been paid within the last 12 months. |
| AWVSf | 26929 | [Pattern 26929] Service occurred within a year of last covered annual wellness visit. | This outpatient edit will set when HCPCS code G0439 is submitted and a previous claim with HCPCS G0438 or G0439 is paid within the last 12 months. |
| CBPf | 31498 | [Pattern 31498] A bilateral procedure code shall be returned when submitted with modifiers LT and RT on a critical access hospital (CAH) claim under revenue code 096x, 097x, or 098x per CMS guidelines. | This outpatient edit will set on a Critical Access Hospital (CAH) claim, bill type 85X, with professional revenue code 096x, 097x or 098x when a claim line with a bilateral procedure is billed with modifier LT and RT. It also sets when a claim contains the same bilateral procedure on two claims lines with the same date of service, one line has modifier RT, and the other line has modifier LT. |
| 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 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 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 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. | 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 |
| FTDf | 6385 | [Pattern 6385] Missing admission date or invalid Statement Covers Period From or Through dates. | This outpatient edit will set when a claim is submitted with a missing or invalid Admission date or Statement Covers Period "From" or "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 (HCPCJ1443) 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 (HCPCJ1444) 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 | 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. |
| 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. |
| 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. |
| 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. |
| 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) (cms.gov) |
| 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. |
| 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 HCPCJ0881 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. |
| OCCf | 20999 | [Pattern 20999] The occurrence code on the claim is invalid. | This inpatient edit will set when a claim is submitted with an invalid occurrence code. |
| 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. |
| 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 | 20949 | [Pattern 20949] The occurrence code on the claim is invalid. | This outpatient edit will set when an invalid occurrence code is used. |
| 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 HCPC90901 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 | 20978 | [Pattern 20978] The occurrence span code on the claim is invalid. | This inpatient edit will set when a claim is submitted with an invalid occurrence span code. |
| 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. |
| 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 HCPCJ0890 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 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 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 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 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 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 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 is past the Medicare institutional timely filing limit. | This outpatient edit will set when the claims 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 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 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 an 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. | 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 for the telehealth site origination facility fee cannot be billed on type of bill. | 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. | 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 HCPCJ0882 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. |