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Noridian Custom Edits (NCE)

NCE Flag NCE Rule ID NCE Description ACE Expression
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
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 a KX 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 the KX modifier is not 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 and the submitted unit are greater than 1
mCO 52 (Pattern 52) Billing for cosurgeons 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
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
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 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
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
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
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 or greater than 124
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.
mTF 20657 (Pattern 20657) The beginning date of service occurred more than 12 months from the entry date which exceeds Medicare timely filing guidelines. For more information, please visit the Noridian Medicare Jurisdiction E Part B website or the Noridian Medicare Jurisdiction F Part B Website 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 NTE segment is empty. When the 2300 and/or 2400 NTE segment is not empty, the edit will be bypassed.
N/A N/A 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.