| Edit Number | Edit Hospital Type | Edit Description | Edit Result/Claim Disposition | Provider Action/Response |
|---|---|---|---|---|
| 81 | OPPS edit | Mental health service not payable outside the partial hospitilization program | This edit occurs when a mental health service that is not payable outside the PH Program is submitted on a 012X or 013X TOB without condition code 41. The claim will be returned to provider. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 82 | OPPS edit | Charge exceeds token charge ($1.01) | This edit occurs when modifier FB is attached to a procedure code and the charge for the device in the covered charge field is greater than the token charge of $1.01. Code C9898 is billed with charges greater than $1.01. This claim will be returned to the provider (RTP) for correction. | The provider should adjust the device charge and reubmit. |
| 83 | Both OPPS and non-OPPS edit | Service provided on or after effective date of NCD non-coverage | This edit occurs when the date that a procedure or service was performed or administered is on or after the effective date of non-coverage thatis contained within the NCD. EXAMPLE: HCPCS CPT code 0085T has and NCD termination date of 12/7/2008. If coded with a Date of Service that is on or after 12/8/2008, then the claim would receive edit 83. The service line will be denied. | The service line will be denied. |
| 84 | OPPS edit | Claim lacks required primary code | Add-on codes 33225, 90785, 90833, 90836 or 90838 are submitted without one of the required primary codes on the same day. (Note: Psychiatric add-on codes are edited only on PHP claims.) Returned to the Provider | Correct claim and resubmit |
| 85 | No longer valid or not active | Claim lacks required device code or required procedure code | Code C9732 and C1840 not submitted together on the same day. (Code for insertion of ocular telescopic lens submitted without the code for the lens, or vice versa). (Active v13.0 ? v14.3) Returned to Provider | Correct and resubmit |
| 86 | OPPS edit | Manifestation code not allowed as principal diagnosis | A diagnosis code considered to be a manifestation code from the MedicareCode Editor (MCE) manifestation diagnosis list is reported as the principal diagnosis code on a hospice bill type claim (081X,082X) Returned to Provider | Correct and resubmit |
| 87 | OPPS edit | Skin substitute application procedure without appropriate skin substitute product code | A List A skin substitute application procedure is submitted without a list A skin substitute product; or a list B skin substitute application procedure is submitted without a list B skin substitute product on the same date of service. Return to Provider | Ensure that hign and low cost skin substitute is reportedwithappropriate application code. |
| 88 | OPPS edit | FQHC payment code not reported for FQHC claim | FQHC payment code not reported for a claim with bill type 077x and without condition code 65. If the bill type is 0770 (No payment claim), edit 88 is not applicable. (Edit 88 is bypassed for FQHC PPS claims when Telehealth originating site services HCPCS code Q3014 or Chronic Care Management HCPCS 99490 is reported and there is no FQHC payment code; also edit 88 is bypassed for FQHC when only FQHC non-covered services are present with edit 91). | TOB 077x must contain a payment code from G0466–G0470. Correct and resubmit |
| 89 | OPPS edit | FQHC claim lacks required qualifying visit code | FQHC payment code reported for FQHC claim (bill type is 077x withoutcondition code 65) without a qualifying visit HCPCS. Edit 89 is bypassedfor FQHC PPS claims when Telehealth originating site services HCPCS codeQ3014 or Chronic Care Management HCPCS 99490 is reported and there is noFQHC payment code or qualifying visit code present; also edit 89 isbypassed for FQHC when only FQHC non-covered services are present withedit 91. eturn to Provider | Visit codes G0466–G0470 must be reported with a qualifying visitcode.Correct and resubmit. |
| 90 | OPPS edit | Incorrect revenue code reported for FQHC payment code | FQHC payment code not reported with revenue code 0519, 052X or 0900.Return to Provider | G0466—G0468 must be reported with rev code 052X or 0519. G0469 and G0470 must be reported with rev code 0900 or 0519. |
| 91 | OPPS edit | Item or service not covered under FQHC PPS or RHC | A service considered to be non-covered under FQHC PPS or for RHC is reported. See FQHC Processing for more information. Rejection | Remove item or service from claim. |
| 92 | OPPS edit | Device-dependent procedure reported without device code | A procedure from the list of device-dependent procedures is reported without a device code. | Add the device code and resubmit. |
| 93 | OPPS edit | Corneal tissue processing reported without cornea transplant procedure | Corneal tissue processing HCPCS (V2785) is reported and there is nocorneal transplant procedure present for the same service date. | Correct and resubmit |
| 94 | No longer valid or not active | Biosimilar HCPCS reported without biosimilar modifier | A biosimilar HCPCS code is reported on the claim without its corresponding biosimilar manufacturing modifier. | Add the modifier and resubmit |
| 95 | OPPS edit | Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service | A PHP claim contains weekly PHP services that total less than 20 hours per 7-day span. This edit applies to v17.2 with a disposition of RTP, and effective v18.3- Present, with a disposition of LIR. This edit is an information only edit it has a LIR disposition, but it will not perform the line rejection due to being defined as information only. | PHP requires a minimum of 20 hours per week of therapeutic services |
| 96 | No longer valid or not active | Partial hospitalization interim claim from and through dates must span more than 4 days | RTP | Resubmit with correct time span. |
| 97 | No longer valid or not active | Partial hospitalization services are required to be billed weekly | RTP | Resubmit with the correct date of service and time span. |
| 98 | OPPS edit | Claim with pass-through device, drug or biological lacks required procedure | RTP | Resubmit with the procedure code |
| 99 | OPPS edit | Claim with pass-through or non-pass-through drug or biological lacks OPPS payable procedure | There is a pass-through drug or biological HCPCS code present on a claim without an associated OPPS procedure with SI = J1, J2, P, Q1, Q2, Q3, R, S, T, U, V. Claim will be returned to the provider for correction (RTP) | Add the corresponding procedure code and resubmit. |
| 100 | OPPS edit | Claim for HSCT allogeneic transplantation lacks required revenuecodeline for donor acquisition services | A claim reporting Hematopoietic stem cell (HSCT) allogeneic transplantation (procedure code 38240) is reported and there is no additional line on the claim reporting revenue code 0815 for donor acquisition services Return to Provider | Correct and resubmit |
| 101 | OPPS edit | Item or service with modifier PN not allowed under PFS | Modifier PN is reported for an item or service that is considered to be non-excepted for an off-campus provider-based hospital outpatient department under Section 603. Return to Provider | Delete modifier PN and resubmit |
| 102 | OPPS edit | Modifier pairing not allowed on the same line | A line item is reported with a pair of modifiers that have conflicting meaning and should not be reported together. Please reference the data files for a report named Modifier Pairs, which contains an up to date list of modifiers not allowed to be reported on the same line. Note: Edit 102 is updated in v20.0 retroactively to inception (1/1/17) , to not allow any conflicting modifiers to be reported on the same line item reporting HCPCS. | Determine the correct modifier, delete the incorrect modifier and resubmit. |
| 103 | No longer valid or not active | Modifier reported prior to FDA approval date | A modifier is reported before its activation date for reporting | Check FDA activation date and correct. |
| 104 | OPPS edit | Service not eligible for all-inclusive rate | An RHC claim (71x) is reported with a line containing the CG modifier. | Remove the CG modifier and resubmit. |
| 105 | OPPS edit | Claim reported with pass-through device prior to FDA approval for the procedure | A procedure is reported with a device before the FDA approval date. The edit is returned on the line containing the device. | Check for the correct HCPCS code. Check FDA approval date. Correct the device HCPCS code. |
| 106 | Both OPPS and non-OPPS edit | Add-on code reported without required primary procedure code | A claim is submitted with a Type I add-on code(s) without the applicable defined primary procedure(s). The edit is returned on the add-on code line(s) when conditions of the edit are not met. Add-on code edits are applied to non-OPPS claims 012X, 013X, 014X, and 085X. Per the IOCE, the edits are also applied to TOBs: 072X, 074x, 075X, 022X, 023X, 032X, 081X, and 082X. | Review list at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html |
| 107 | Both OPPS and non-OPPS edit | Add-on code reported without required contractor-defined primary procedure code | A claim with bill type 085x (CAH) is submitted with a Type II add-on code(s) reported with a professional services revenue code (096x, 097x or 098x), to allow for contractors to review and define the primary procedure on the claim. .Add-on code edits are applied to non-OPPS claims 012X, 013X, 014X, and 085X. Per the IOCE, the edits are also applied to TOBs: 072X, 074x, 075X, 022X, 023X, 032X, 081X, and 082X. | Review list at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html |
| 108 | Both OPPS and non-OPPS edit | Add-on code reported without required primary procedure orrequiredcontractor-defined primary procedure code | A claim is submitted with a Type III add-on code(s) without a defined primary(s) or contractor defined primary(s) on the same day. This edit is returned on the reported add-on code line(s) when conditions are not met. Add-on code edits are applied to non-OPPS claims 012X, 013X, 014X, and 085X. Per the IOCE, the edits are also applied to TOBs: 072X, 074x, 075X, 022X, 023X, 032X, 081X, and 082X. | Review list at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html |
| 109 | OPPS edit | Code first diagnosis present without mental health diagnosis as the first secondary diagnosis | A PHP claim is submitted with a Code First Diagnosis without a mental health diagnosis in the first secondary diagnosis position. If the first secondary diagnosis position is blank edit 109 is still returned. Note: Edit 29 is suppressed from being returned if a code first diagnosis is present in the pdx position. Return to Provider | Correct order of diagnoses or add a mental health diagnosis |
| 110 | Both OPPS and non-OPPS edit | Service provided prior to initial marketing date | The reported line item date of service of a code is prior to the initial marketing date, for which it can be reported. For HCPCS Q5115, this edit will apply if reported before 11/11/2019. Line item Rejection | Research date and if this edit is correct, write off the service. |
| 111 | Both OPPS and non-OPPS edit | Service cost is duplicative; included in cost of associated biological. | The reported line item is considered duplicative as the routine costs of all steps in creating a biological are bundled into the covered benefit, the biological. Any procedure identified as being ?bundled into biological? and reported as a line item are rejected. Additionally, this edit is returned if revenue codes 870-873 are submitted as line items with blank HCPCS. Line Item Rejection | Research and write off the incorrect charge. |
| 112 | Both OPPS and non-OPPS edit | Information only service(s) | The reported line item is a non-covered service as it is for informational reporting purposes only. Any HCPCS identified as being an information only service is assigned a non-covered status indicator and is line item rejected with no impact on payment. Line Item Rejection | Take into advisement |
| 113 | Both OPPS and non-OPPS edit | Supplementary or additional code not allowed as principal diagnosis | The principal diagnosis code reported is considered supplementary or an additional code and cannot be used as the principal diagnoses. The unacceptable principal diagnosis list is defined by the Medicare Code Editor (MCE) but there are some exclusions to the MCE list due to current OPPS coding requirements and guidelines. Any diagnosis code flagged as being an exclusion to the Unacceptable Principal Diagnosis list does not return edit 113. | Determine the correct principal diagnosis, delete the incorrect diagnosis and resubmit. |
| 114 | Both OPPS and non-OPPS edit | Item or service not allowed with modifier CS | Modifier CS is reported on an item or service that is not on the coinsurance waiver eligible list. Modifier CS should only be reported on items that are identified by CMS as being eligible for a coinsurance waiver. Refer to the DATA_HCPCS table and column for named coinsurance_waiver_eligible for the list of services that are appropriate to report with modifier CS. | Determine the correct service from the coinsurance waiver eligible list, delete the incorrect service and resubmit. |
| 115 | Both OPPS and non-OPPS edit | COVID-19 lab add-on code reported without required primary procedure | HCPCS U0005 is reported on a claim without one of its primary procedures U0003 or U0004 on the same date of service. Note: U0005 may be considered a Type I add-on code but it has been given a separately distinct function than regular addon code edit 106. This add-on code is only subject to edit 115 in the IOCE. | Determine if primary procedure has been added. If U0005 has been submitted without U0003 or U0004 add on one of the primary procedure codes. |
| 116 | Both OPPS and non-OPPS edit | Opioid treatment program service not payable outside the opioid treatment program | Opioid Treatment Program HCPCS codes are reported on a bill type that is not approved for an Opioid Treatment Program provider. Opioid Treatment Program HCPCS codes should only be reported on claims with bill types 87x, 13x with condition code 89, or 85x with condition code 89x. | Verify which bill type has been submitted. Update to bill type 87x, 13x with condition code 89, or 85x with condition code 89x if necessary. |
| 117 | OPPS edit | Token charge less than $1.01 billed by provider | A drug HCPCS with final SI=K or G is reported with charges that are less than $1.01 and at least $0.01. The edit is not applied if a line item action flag of 2,3, or 4 is present on the drug line(s). | Verify charges. |
| 118 | Both OPPS and non-OPPS edit | Invalid bill type | A claim submitted with a bill type that is not programmed to process in the IOCE. The presence of this edit terminates the processing of the claim, claim processed flag value 1 and return code 18 are provided. Edit 118 is not specified in the edits by bill type table as this edit can only be applied to bill types that are not programmed in the IOCE. | Verify that type of bill is valid. |
| 119 | Both OPPS and non-OPPS edit | Invalid claim processing receipt date | The claims processing receipt date is invalid or the date falls outside the range of any version of the IOCE program. This edit is an IOCE program error and is applicable to being returned on all programmed bill types. The claim processed flag value 1 and return code 29 are provided if edit 119 is applied. | Verify receipt date and update if necessary. |
| 120 | Both OPPS and non-OPPS edit | Incorrect reporting of modifier PT | A claim is submitted with only one procedure from the designated surgical ranges (10000–69999)or (0000T–9999T) and reported with modifier PT for a single date of service. This edit is returned at the line level. | Remove modifier PT if applied incorrectly. |
| 121 | OPPS edit | Non-covered service reported with inpatient only procedure where patient is expired or transferred | Non-covered services, identified with status indicators B, E1, E2, C or M, should not be paid separately when reported on a claim with inpatient-only procedure and modifier CA. | Remove non-covered services from the claim if there is an inpatient-only procedure with modifier CA reported. |
| 122 | OPPS edit | 340B-acquired drug modifier(s) reported inappropriately | Pass-through drug and biological (SI=G) incorrectly reported with 340B program modifier. This is an information only edit that sets the Line Item Denial Rejection flag = 3. | Remove 340B program modifier from the pass-through drug and biological code. These codes are assigned to status indicator G. |
| 123 | Both OPPS and non-OPPS edit | Modifier used after CMS termination date | The reported claim is submitted with a HCPCS and appended with a modifier designated as not reportable after the CMS determined termination date for the modifier (Example modifier(s) includes: CS). Note: A line item action flag of 1 overrides this edit when input by the MAC. | Check date of service submitted to be sure it is not after termination date for the modifier reported. |
| 124 | Both OPPS and non-OPPS edit | HCPCS reported after CMS termination date | The reported claim is submitted with a HCPCS on a date of service after the CMS determined termination date. Refer to the DATA-HCPCS table and the column names “CMS_Mid-Quarter_Termination” for a list of codes applicable. NOTE: A line item action flag of 1 overrides this edit when input by the MAC. | Check date of service submitted to be sure it is not after termination date for the HCPCS reported. |
| 125 | OPPS edit | Incorrect billing of IMRT planning and delivery | This edit will identify when a code is present that should not be reported on the same claim as 77301 (Intensity Modulated Radiotherapy Plan). Refer to the Map_IMRT table for list of applicable codes. Note: The applicable codes are not separately reportable on the same claim since they are already included in the APC payment or should not be reported for verification of the treatment field during a course of IMRT. | Remove code from claim that should not be reported with 77301. |
| 126 | Both OPPS and non-OPPS edit | Incorrect reporting of telehealth modifier | A code not flagged as “Telehealth” is present with modifiers 95, GT or GQ. Refer to the Telehealth column in Data_HCPCS for allowable service codes as designated by CMS. | Remove service from claim that is being flagged as telehealth but it not designated by CMS as telehealth. |
| 127 | Both OPPS and non-OPPS edit | Service not allowed for Part B Inpatient Claim | The revenue code reported is not on the allowable list for a Part B Inpatient claim, bill type 12x. Note: Edit 127 is bypassed when there is an allowable HCPCS present without a Part B Inpatient billable revenue code. Additionally, this edit is bypassed when condition code W2 is present. For a list of allowable revenue codes, see the Part B Billable Inpatient Revenue list in Data_Revenue. For a list of allowable HCPCS codes, see the Part B Billable Inpatient HCPCS list in the Data_HCPCS. | Remove service from claim that is not allowable on Part B Inpatient claims. |
