|
| 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 |
| Partial hospitalization service for non-mental health diagnosis |
| Insufficient services on day of partial hospitalization |
| 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) |
| Weekly partial hospitalization services require a minimum of 20 hours of service as evidenced in PHP plan of care (v17.2 only-RTP, v18.3-present, LIR) |
| 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 |
| IOP Primary service not reported for IOP claim |
| PHP Primary service not reported for PHP claim |
