| 1 | INVALID DIAGNOSIS OR PROCEDURE CODE | The Medicare Code Editor checks each diagnosis including the admitting diagnosis and each procedure against a table of valid ICD-10-CM and ICD-10-PCS codes. If an entered code does not agree with any code on the internal list, it is assumed to be invalid. |
| 2 | EXTERNAL CAUSES OF MORBIDITY CODES AS PRINCIPAL | External causes of morbidity codes are ICD-10-CM codes beginning with the letter V through Y. They describe the circumstance causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. |
| 3 | DUPLICATE OF PDX | Whenever a secondary diagnosis is coded the same as the principal diagnosis, the secondary diagnosis is identified as a duplicate of the principal diagnosis. |
| 4 | AGE CONFLICT | The Medicare Code Editor detects inconsistencies between a patient’s age and any diagnosis on the patient’s record. For example, a five-year-old patient with benign prostatic hypertrophy or a 78-year-old patient coded with a delivery. In these cases, the diagnosis is clinically and virtually impossible in a patient of the stated age. Therefore, either the diagnosis or the age is presumed to be incorrect. There are four age categories for diagnoses in the program.• Newborn. Age 0 years only; a subset of diagnoses which will only occur during the perinatal or newborn period of age 0 (e.g., tetanus neonatorum, health examination for newborn under 8 days old) • Pediatric. Age range is 0–17 years inclusive (e.g., Reye’s syndrome, routine child health exam) • Maternity. Age range is 9-64 years inclusive (e.g., diabetes in pregnancy, antepartum pulmonary complication) • Adult. Age range is 15–124 years inclusive (e.g., senile delirium, mature cataract) |
| 5 | SEX CONFLICT | Medicare Code Editor detects inconsistencies between a patient’s sex and any diagnosis or procedure on the patient’s record. For example, a male patient with cervical cancer (diagnosis) or a female patient with a prostatectomy (procedure). In both instances, the indicated diagnosis or the procedure conflicts with the stated sex of the patient. Therefore, either the patient’s diagnosis, procedure or sex is presumed to be incorrect. |
| 6 | MANIFESTATION CODE AS PRINCIPAL DIAGNOSIS | Manifestation codes describe the manifestation of an underlying disease, not the disease itself, and therefore should not be used as a principal diagnosis. |
| 7 | NON-SPECIFIC PRINCIPAL DIAGNOSIS | Effective 10/01/07, the non-specific principal diagnosis edit was discontinued and will appear for claims processed using MCE version 2.0–23.0 only. |
| 8 | QUESTIONABLE ADMISSION | Some diagnoses are not usually sufficient justification for admission to an acute care hospital. For example, if a patient is given code R03.0 for elevated blood pressure reading, without diagnosis of hypertension, then the patient would have a questionable admission, since elevated blood pressure reading is not normally sufficient justification for admission to a hospital. |
| 8 | Questionable obstetric admission | These ICD-10-PCS procedure codes describing either a cesarean section or vaginal delivery are considered to be a questionable admission except when reported with a corresponding secondary diagnosis code describing the outcome of delivery. |
| 9 | UNACCEPTABLE PRINCIPAL DIAGNOSIS | There are selected codes that describe a circumstance which influences an individual’s health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis. |
| 9 | Unacceptable principal diagnosis unless secondary diagnosis present | The identified unacceptable principal diagnosis code is considered “acceptable” when a secondary diagnosis is also coded on the record. If no secondary diagnosis is present for this code, the message REQUIRES SECONDARY DX should appear. |
| 10 | NON-SPECIFIC O.R. PROCEDURE | Effective 10/01/07, the non-specific O.R. procedure edit was discontinued and will appear for claims processed using MCE version 2.0–23.0 only. |
| 11 | NON-COVERED PROCEDURE | There are some procedures for which Medicare does not provide reimbursement. There are also procedures that would normally not be reimbursed by Medicare but due to the presence of certain diagnoses are reimbursed. These procedures are identified as always non-covered procedures. |
| 11 | Non-covered pancreas transplants | These procedures are identified as non-covered procedures except when combined with principal or secondary diagnosis codes from this diagnosis list OR when combined with a kidney transplant procedure code. |
| 11 | Non-covered stem cell or bone marrow transplants | These procedures are identified as non-covered procedures only when any code from the diagnoses list is present as either a principal or secondary diagnosis. |
| 11 | Non-covered procedures for multiple myeloma | This edit was discontinued on 10/01/2018. |
| 11 | Non-covered procedures for beneficiary over age 60 | These procedures are non-covered when the beneficiary is over age 60. |
| 11 | Non-covered sterilization procedures | These procedures are identified as non-covered procedures only when combined with principal or secondary diagnosis code Z30.2 (Encounter for sterilization). |
| 11 | Non-covered combined replacement of right and left ventricle with synthetic substitute | This edit was discontinued on 04/01/2022. |
| 12 | OPEN BIOPSY CHECK | Effective 10/01/10, the open biopsy check edit was discontinued and will appear for claims processed using MCE version 2.0–26.0 only. |
