Each edit is associated with a disposition. For example, there can be a rejection of the line item itself or a rejection of the entire claim. In addition to edit dispositions, the program assigns an overall disposition to the claim. The below lists the edits currently applied to non-OPPS hospital outpatient claims with their dispositions.

A disposition is assigned based on the presence of any edits on a line. The meaning of each edit  disposition is described in the following table. It is possible for a claim to have one or more edits in all dispositions.

Below are the different disposition and their definition

Claim rejection – provider can correct and resubmit the claim but cannot appeal the rejection.

Claim denial – The provider cannot resubmit the claim but can appeal the denial.

Claim return to provider (RTP) -The provider can resubmit the claim once the problems are corrected.

Claim suspension – The claim is not returned to the provider, but it is not processed for payment until the fiscal intermediary/Medicare Administrative Contractor (FI/MAC) makes a determination or obtains further information.

Line item rejection – The claim can be processed for payment with some line items rejected for payment (i.e., the line item can be corrected and resubmitted but cannot be appealed).

Line item denial – There are one or more edits that cause one or more individual line items to be denied. The claim can be processed for payment with some line items denied for payment (i.e., the line item cannot be resubmitted but can be appealed).

Read also: List of  status indicators and Payment indicators

Edit disposition summary

1. Invalid diagnosis code –Claim returned to provider
2. Diagnosis and age conflict – Claim returned to provider
3. Diagnosis and sex conflict – Claim returned to provider
5. External cause of morbidity code cannot be used as principal –diagnosis Claim returned to provider
6. Invalid procedure code – Claim returned to provider
7. Procedure and age conflict – Line item rejection (Informational only, no impact to payment)
8. Procedure and sex conflict – Claim returned to provider
9. Non-covered under any Medicare outpatient benefit, for reasons other than statutory exclusion – Line item denial
10. Service submitted for denial (condition code 21)Edit 10 also terminates processing early and returns Claim Processed Flag of 3 (Claim could not be processed (edit 10 – condition code 21 is present)), and a Return Code of 20 (Claim was not processed, condition code 21 exists). Edit 10, and edits 23 and 24 for from /through dates, are not dependent on the Edits by Bill Type Tables for OPPS or Non-OPPS. –Claim denial
11. Service submitted for FI/MAC review (condition code 20) – Claim suspension
12. Questionable covered service –Claim suspension
13. Separate payment for services is not provided by Medicare – Line item rejection
15. Service unit out of range for procedure – Claim returned to provider
17. Inappropriate specification of bilateral procedure – Line item rejection
20. Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is present –Line item rejection
22. Invalid modifier –Claim returned to provider

23. Invalid date –Claim returned to provider
24. Date out of OCE range –Claim suspension
25. Invalid age –Claim returned to provider
26. Invalid sex –Claim returned to provider
28. Code not recognized by Medicare for outpatient claims; alternate code for same service may be available –Line item rejection
40. Code2 of a code pair that would be allowed by NCCI if appropriate modifier were present –Line item rejection
41. Invalid revenue code –Claim returned to provider
44. Observation revenue code on line item with non-observation HCPCS code –Claim returned to provider
46. Partial hospitalization condition code 41 not approved for type of bill –Claim returned to provider
48. Revenue center requires HCPCS –Claim returned to provider
50. Non-covered under any Medicare outpatient benefit, based on statutory exclusion –Claim returned to provider
51. Observation code G0378 not allowed to be reported more than once per claim –Claim returned to provider
53. Codes G0378 and G0379 only allowed with bill type 13x or 85x –Line item rejection
54. Multiple codes for the same servicea –Claim returned to provider
55. Non-reportable for site of service –Claim returned to provider
61. Service can only be billed to the DMERC –Claim returned to provider
62. Code not recognized by OPPS; alternate code for same service may be available –Claim returned to provider
65. Revenue code not recognized by Medicare –Line item rejection
67. Service provided prior to FDA approval –Line item denial
68. Service provided prior to date of National Coverage Determination (NCD) approval –Line item denial
69. Service provided outside approval period –Line item denial
72. Service not billable to the Medicare Administrative Contractor –Claim returned to provider
74. Units greater than one for bilateral procedure billed with modifier 50 –Claim returned to provider

83. Service provided on or after effective date of NCD non-coverage –Line item denial
84. Claim lacks required primary code –Claim returned to provider
86. Manifestation code not allowed as principal diagnosis –Claim returned to provider
88. FQHC payment code not reported for FQHC claim –Claim returned to provider
89. FQHC claim lacks required qualifying visit code –Claim returned to provider
90. Incorrect revenue code reported for FQHC payment code –Claim returned to provider
91. Item or service not covered under FQHC PPS or for RHC –Line item rejection
93. Corneal tissue processing reported without cornea transplant procedure –Line item rejection
94. Biosimilar HCPCS reported without biosimilar modifier (v17.0–v19.0 only) –Claim returned to provider
100. Claim for HSCT allogeneic transplantation lacks required revenue code line for donor acquisition services –Claim returned to provider
102. Modifier pairing not allowed on the same line –Claim returned to provider
103. Modifier reported prior to FDA approval date (v19.0 only) –Line item denial
104. Service not eligible for all-inclusive rate –Line item rejection
106. Add-on code reported without required primary procedure code –Line item denial
107. Add-on code reported without required contractor-defined primary procedure code –Line item denial
108. Add-on code reported without required primary procedure or without required contractor-defined primary procedure code –Line item denial
110. Service provided prior to initial marketing date –Line item rejection
111. Service cost is duplicative; included in cost of associated biological. –Line item rejection
112. Information only service(s) –Line item rejection
113. Supplementary or additional code not allowed as principal diagnosis –Claim returned to provider
114. Item or service not allowed with modifier CS –Claim returned to provider
115. COVID-19 lab add-on code reported without required primary procedure –Line item denial

116. Opioid treatment program service not payable outside the opioid treatment program –Claim returned to provider
118. Invalid bill type –Claim returned to provider
119. Invalid claim processing receipt date –Claim returned to provider
120. Incorrect reporting of modifier PT –Claim returned to provider
123. Modifier used after CMS termination date –Claim returned to provider
124. HCPCS reported after CMS termination date –Claim returned to provider