MC_PRICER_IOCE_EDITS

Description: |
This table contains edits returned from the CMS Integrated Outpatient Code Editor (IOCE) output from the Epic Pricer during adjudication.

Primary Key

Column Name | Ordinal Position |
--- | --- | ---
PRICER_MSG_ID | 1 |
LINE | 2 |

Column Information

| Name | Type | Discontinued? |
--- | --- | --- | --- | ---
1 | PRICER_MSG_ID | NUMERIC | No |
The unique identifier for the Epic Pricer message record.
2 | LINE | INTEGER | No |
The line number for the information associated with this record. Multiple pieces of information can be associated with this record.
3 | IOCE_EDIT_C_NAME | VARCHAR | No |
Edits returned from the CMS Integrated Outpatient Code Editor (IOCE) output from Epic Pricer.
May contain organization-specific values: No
Category Entries:
Invalid diagnosis code
Diagnosis and age conflict
Diagnosis and sex conflict
Medicare secondary payer alert (v1.0 and v1.1 only)
E-diagnosis code can not be used as principal diagnosis
Invalid procedure code
Procedure and age conflict
Procedure and sex conflict
Non-covered under any Medicare outpatient benefit, for reasons other than statutory exclusion
Service submitted for denial
Service submitted for FI/MAC review (condition code 20)
Questionable covered service
Separate payment for services is not provided by Medicare
Code indicates a site of service not included in OPPS (v1.0-v6.3 only)
Service unit out of range for procedure
Multiple bilateral procedures without modifier 50 (v1.0-v6.2 only)
Inappropriate specification of bilateral procedure
Inpatient procedure
Mutually exclusive procedure that is not allowed by NCCI even if appropriate modifier is present (deleted, combined with edit 20 retroactive to earliest included version)
Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is present
Medical visit on same day as a type T or S procedure without modifier 25
Invalid modifier
Invalid date
Date out of OCE range
Invalid age
Invalid sex
Only incidental services reported
Code not recognized by Medicare for outpatient claims; alternate code for same service may be available
PHP/IOP service for non-mental health diagnosis
Insufficient services on day of partial hospitalization (inactive)
Partial hospitalization on same day as ECT or type T procedure (v1.0-v6.3 only)
Partial hospitalization claim spans 3 or less days with insufficient services on at least one of the days (v1.0-v9.3)
Partial hospitalization claim spans more than 3 days with insufficient number of days having mental health services (v1.0-v9.3)
Partial hospitalization claim spans more than 3 days with insufficient number of days meeting partial hospitalization criteria (v1.0-v9.3)
Only Mental Health education and training services provided
Extensive mental health services provided on day of ECT or type T procedure (v1.0-v6.3 only)
Terminated bilateral procedure or terminated procedure with units greater than one
Inconsistency between implanted device or administered substance and implantation or associated procedure
Mutually exclusive procedure that would be allowed by NCCI if appropriate modifier were present (deleted, combined with edit 40 retroactive to earliest included version)
Code2 of a code pair that would be allowed by NCCI if appropriate modifier were present
Invalid revenue code
Multiple medical visits on same day with same revenue code without condition code G0
Transfusion or blood product exchange without specification of blood product
Observation revenue code on line item with non-observation HCPCS code
Inpatient separate procedures not paid
Partial hospitalization condition code 41 not approved for type of bill
Service is not separately payable
Revenue center requires HCPCS
Service on same day as inpatient procedure
Non-covered under any Medicare outpatient benefit, based on statutory exclusion
Observation code G0378 not allowed to be reported more than once per claim
Observation does not meet minimum hours, qualifying diagnoses, and/or ‘T’ procedure conditions (v3.0-v6.3 only)
Codes G0378 and G0379 only allowed with bill type 13x or 85x
Multiple codes for the same service
Non-reportable for site of service
E/M condition not met and line item date for obs code G0244 is not 12/31 or 1/1 (v4.0-v6.3 only)
Composite E/M condition not met for observation and line item date for code G0378 is 1/1
G0379 only allowed with G0378
Clinical trial requires diagnosis code V707 as other than primary diagnosis (deleted, retroactive to the earliest included version)
Use of modifier CA with more than one procedure not allowed
Service can only be billed to the DMERC
Code not recognized by OPPS; alternate code for same service may be available
This OT code only billed on partial hospitalization claims (v1.0-v13.3)
AT service not payable outside the partial hospitalization program (v1.0-v13.3)
Revenue code not recognized by Medicare
Code requires manual pricing
Service provided prior to FDA approval
Service provided prior to date of National Coverage Determination (NCD) approval
Service provided outside approval period
CA modifier requires patient discharge status indicating expired or transferred
Claim lacks required device code (v6.1-v15.3 only)
Service not billable to the Fiscal Intermediary/Medicare Administrative Contractor
Incorrect billing of blood and blood products
Units greater than one for bilateral procedure billed with modifier 50
Incorrect billing of modifier FB or FC (v.8.0-v15.3 only)
Trauma response critical care code without revenue code 068x and CPT 99291
Claim lacks allowed procedure code (v6.1-v15.3 only)
Claim lacks required radiolabeled product (v9.0-v14.3)
Incorrect billing of revenue code with HCPCS code
Mental health code not approved for partial hospitalization program
Mental health service not payable outside the partial hospitalization program
Charge exceeds token charge ($1.01)
Service provided on or after effective date of NCD non-coverage
Claim lacks required primary code
Claim lacks required device code or required procedure code (v13.0-v14.3)
Manifestation code not allowed as principal diagnosis
Skin substitute application procedure without appropriate skin substitute product code
FQHC payment code not reported for FQHC claim
FQHC claim lacks required qualifying visit code
Incorrect revenue code reported for FQHC payment code
Item or service not covered under FQHC PPS
Device-intensive procedure reported without device code
Corneal tissue processing reported without cornea transplant procedure
Biosimilar HCPCS reported without biosimilar modifier (v17.0-v19.0 only)
7-day spanning partial hospitalization services require a minimum of 20 hours of service as evidenced in PHP plan of care
Partial hospitalization interim claim From and Through dates must span more than 4 days
Partial hospitalization services are required to be billed weekly
Claim with pass-through device, drug or biological lacks required procedure
Claim with pass-through or non-pass-through drug or biological lacks OPPS payable procedure
Claim for HSCT allogeneic transplantation lacks required revenue code line for donor acquisition services
Item or service with modifier PN not allowed under PFS
Modifier pairing not allowed on the same line
Modifier reported prior to FDA approval date (v19.0 only)
Service not eligible for all-inclusive rate
Claim reported with pass-through device prior to FDA approval for procedure
Add-on code reported without required primary procedure code
Add-on code reported without required contractor-defined primary procedure code
Add-on code reported without required primary procedure or without required contractor-defined primary procedure code
Code first diagnosis present without mental health diagnosis as the first secondary diagnosis
Service provided prior to initial marketing date
Service cost is duplicative; included in cost of associated biological
Information only service(s)
Supplementary or additional code not allowed as principal diagnosis
Item or service not allowed with modifier CS
COVID-19 lab add-on code reported without required primary procedure
Opioid treatment program service not payable outside the opioid treatment program
Token charge less than $1.01 billed by provider
Invalid bill type
Invalid claim processing receipt date
Incorrect reporting of modifier PT
Non-covered service reported with inpatient only procedure where patient expired or transferred
340B-acquired drug modifier(s) reported inappropriately
Modifier used after CMS termination date
HCPCS reported after CMS termination date
Incorrect billing of IMRT planning and delivery
Incorrect reporting of telehealth modifier
Service not allowed for Part B Inpatient claim
Insufficient services on day of IOP
7-day spanning IOP services require a minimum of 9 hours of service
Incorrect reporting of modifier on RHC IOP claim
Insufficient services on day of PHP
Mental health code not approved for Intensive Outpatient Program
Mental health service not payable outside the Intensive Outpatient Program
Service provided outside designated approval period
Claim Day lacks required device code
Service provided prior to ACIP approval date
More than 2 non-opioid pain relief devices reported
IOP Primary service not reported for IOP claim
PHP Primary service not reported for PHP claim
4 | IOCE_EDIT_TYPE_C_NAME | VARCHAR | No |
Edit type associated with the edit from IOCE_EDIT_C column.
May contain organization-specific values: No
Category Entries:
Claim rejection
Claim denial
Claim return to provider
Claim suspension
Line item rejection
Line item denial