| Edit Number | Edit Hospital Type | Edit Description | Edit Result/Claim Disposition | Provider Action/Response |
|---|---|---|---|---|
| 1 | Both OPPS and non-OPPS edit | Invalid diagnosis code | This edit occurs when the principal diagnosis field is blank, there are no diagnoses listed, or the diagnosis code is not valid for the selected version of the program. Each ICD-10-CM diagnosis code is edited for completeness and validity. Codes without the required number of digits are considered invalid. Codes are also checked to insure that they were valid at the time of the patient’s visit. Date validity is tested using the “from date” on the claim. If the claim does not contain at least one diagnosis code, this error is also generated. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 2 | Both OPPS and non-OPPS edit | Diagnosis and age conflict | This edit occurs when the diagnosis code includes an age range, and the age reported is outside the range. It indicates that the diagnosis code is inconsistent with the patient’s age. Age categories are as follows:Newborn (age = 0) Pediatric (age = 0 to 17 years) Maternity (age= 9 to 64 years) Adult (age= 15 to 124) All ages (age 0 to 124 ) EXAMPLES: O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery is appropriate only for newborn patients. G93.7 Reye’s Syndrome is appropriate for pediatric patients only. O00.80 Other ectopic pregnancy without intrauterine pregnancy is appropriate for maternity patients only. J61 Pneumoconiosis due to asbestosis is appropriate only for adults. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 3 | Both OPPS and non-OPPS edit | Diagnosis and sex conflict | This edit occurs when the diagnosis code includes a sex designation and the sex reported for the patient does not match. It indicates that the diagnosis code is inconsistent with the patient’s sex. *This edit is bypassed if condition code 45, ambiguous gender, is present. EXAMPLES: C53.0 Malignant neoplasm of endocervix is considered appropriate only for female patients. Z98.52 Vasectomy status is appropriate for males only. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 4 | No longer valid or not active | Medicare secondary payer alert (V1.0 and V1.1 only) | This edit occurs when the procedure code reported has an MSP warning indicator associated with it. The diagnosis code may signal a condition (generally some type of trauma) for which Medicare is the secondary payer. The edit is not applicable for admitting or patient’s reason for visit diagnosis. EXAMPLES (Version 2 only): The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the FI makes a determination or obtains further information. |
| 5 | Both OPPS and non-OPPS edit | External cause of morbidity code cannot be used as principal diagnosis | These codes describe the circumstances that caused an injury or health condition, the intent, the place where the event occurred, the activity of the patient at the time of the event or the patient?s status. These ICD-10-CM codes are not acceptable by themselves or as the primary diagnosis and would generate the edit if listed by themselves or as the primary diagnosis. EXAMPLES: V00.111A Fall from in-line roller skates, initial encounter; Y08.02xA Assault by strike by baseball bat, initial encounter. This edit is not applicable for admitting or patient’s reason for visit diagnoses. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 6 | Both OPPS and non-OPPS edit | Invalid procedure code | This edit occurs when the HCPCS code reported is not valid for the selected version of the OCE program. Each HCPCS Level I or Level II procedure code is edited for completeness and validity. This edit indicates that the HCPCS code is invalid or was not valid for the patient’s dates of service. Date validity is verified using the From Date on the claim. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 7 | No longer valid or not active | Procedure and age conflict (not activated) | This edit occurs when the procedure code reported has an age range associated with it and the age of the patient is outside that range. Each procedure is assigned a valid minimum and valid maximum age. If the patient age falls outside of this range, the procedure is flagged as an error. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 8 | Both OPPS and non-OPPS edit | Procedure and sex conflict | This edit occurs when the procedure code reported has a sex designation associated with it and the sex of the patient does not match the designated sex. *This edit is bypassed if condition code 45, ambiguous gender, is present. EXAMPLES: 53430 Female Urethra Reconstruction is considered valid for female patients only. 55250 Vasectomy is considered valid for males only.Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 9 | Both OPPS and non-OPPS edit | Noncovered under any Medicare outpatient benefit, for reasons other than statutory exclusion | This edit occurs when the procedure code has a noncovered service indicator. It identifies services that are never paid under the Medicare program. The services in this list are a subset of the services assigned to payment status of “E” (non-covered service). EXAMPLES: The result of this edit will be a line item denial. | There may be one or more edits that cause one or more line items to be denied. The claim can be processed for payment with some line items denied for payment. The denied line item cannot be resubmitted but it can be appealed. |
| 10 | Both OPPS and non-OPPS edit | Service submitted for denial (condition code [UB-4 FL 18-28] 21) | This edit occurs when the claim has a condition code 21, Request for Denial Notification, reported in FLs 18-28. It identifies services that are billed by a provider for a denial notice. The claim will be denied. | The provider cannot correct and resubmit the claim but they can appeal the denial. |
| 11 | Both OPPS and non-OPPS edit | Service submitted for MAC review (condition code [UB-4 FL 18-28] 20) | This edit occurs when the claim has a condition code 20, Request for MAC Review, reported in FLs 18-28. It identifies non-covered services that are billed by the provider when a beneficiary requests a Medicare review for coverage. The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the MAC makes a determination or obtains further information. |
| 12 | Both OPPS and non-OPPS edit | Questionable covered service | This edit occurs when the procedure code reported has a questionable covered service indicator. It identifies procedures that are only covered by the Medicare program under certain medical circumstances. | A suspended claim is not returned to the provider but will notbeprocessed for payment until the MAC makes a determination or obtains further information. |
| 13 | OPPS edit | Separate payment for services is not provided by Medicare (V1.0-V6.3 and V18.0–) | This edit identifies services that are not reportable to Medicare, but may be reportable to other insurers. his edit occurs when the claim is an OPPS claim and the TOB code (FL 4) is 12X or 13X and condition code 41 (FLs 18-28) is not reported and the HCPCS code is on the “service not paid by Medicare” list (payment status “B” or “E”. This error also occurs when the claim is non-OPPS and the TOB code is any other than those defined for OPPS above, and the HCPCS code is on the “service not paid by Medicare” list, and the service indicator is not B. EXAMPLE (Prior to January 1, 2006 only): A claim with bill type 13X, and CPT code 77263, Therapeutic Radiology Treatment Planning Complex, would generate edit 013. Line item rejection. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 14 | No longer valid or not active | Code indicates a site of service not included in OPPS (V1.0-V6.3 only) | This edit identifies codes that describe services not generallyperformed in the hospital outpatient setting. These services are notcovered under OPPS and include codes for home health services, rest homevisits and hospice visits.EXAMPLES (Prior to January 1, 2006 only):59400 Routine Obstetric Care 99401 Preventive Counseling Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 15 | No longer valid or not active | Service units out of range for procedure | This edit is inactive. It had occurred when the number of units reported in FL 46 reported are clinically impossible or unreasonable for the service billed. Units from all line items with the same procedure code on the same date of service will be added together before this edit isapplied. The presence of modifier 91 may override this edit for certain laboratory procedures. This edit has been replaced with the medically unlikely edits (MUEs) | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 16 | No longer valid or not active | Multiple bilateral procedures without modifier 50 (V1.0-V6.2 only) | This edit occurs when multiple exclusive bilateral procedure codes are reported, and the same bilateral procedure code appears two or more times for the same date of service, all without modifier 50. An exclusively conditional bilateral code represents a service that can be, but is not always, performed bilaterally. When performed bilaterally a modifier of 50 must be used, and the entire service is paid at 150% of the fee for a non-bilateral service. (The first service is paid at 100% and the second at 50%.) This edit does not apply to inherently bilateral, independently bilateral or non-bilateral codes. This edit applied prior to 10/01/05 only. NOTE: CMS removed all codes from the “exclusively bilateral” list effective October 1, 2005. This change effectively eliminated this edit starting October 1, 2005. EXAMPLE (Prior to October 1, 2005 only): Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 17 | Both OPPS and non-OPPS edit | Inappropriate specification of bilateral procedure | This edit occurs when the same inherently bilateral procedure code appears two or more times on the same date of service. This edit is applied to all relevant bilateral procedure lines, except when modifier 76 or 77 is submitted on the second or subsequent line or units of an inherently bilateral code. Note: For codes with an SI of V (visit) that are also on the Inherent Bilateral list, condition code G0 will take precedence over the bilateral edit; these claims will not receive edit 17. This edit is also bypassed if the bill type is 085x. EXAMPLE: 11010 Debridement of Skin appearing on two different claim lines for the same service date. Both claim lines will be flagged with this edit. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 18 | OPPS edit | Inpatient procedure | CMS has established a list of procedures that it believes can only be safely performed in the inpatient setting. In most cases, Medicare will not pay for these procedures when they are performed in the outpatient setting. A line has a C status indicator and is not on the separate procedure list or A line has a C status indicator and is on the separate procedure list, but there are no type T lines on the same day. All other line items on the same day as the line with a C status indicator are denied (line item denial/rejection flag = 1, APC return buffer) and edit 49 is assigned on all line items. *This is the only edit that can cause one or more days of a multiple-day claim to be denied, or single day claim with all lines denied. No other edits are performed on any lines with edits 18 or 49. Inpatient only services may be eligible for payment when modifier CA is submitted, indicating that the patient received this service on an emergency basis, but then died before the hospital could admit or transfer the patient. Effective January 1, 2016, this inpatient service is paid under APC 5881, Ancillary Service Patient Expires. In this case, all other services provided on the same date are not assigned edit 049, but instead are packaged into the APC 5881 payment. EXAMPLE 1: 27025 – Hip/Thigh Fasciotomy is considered to be an “inpatient only” procedure and is not on the “Separate Procedures” list. This procedure, and all other services on the claim with the same service date, would be flagged by the OCE for line item rejection. EXAMPLE 2: 27005 – Incision of hip tendon is an “inpatient only” procedure that is also found on the “Separate Procedures” code list. In the absence of a type “T” procedure on the same date, edit 018 would be assigned to this CPT code and all services on the claim with the same service date would be flagged for line item rejection. | There may be one or more edits that cause one or more line items to be denied. The claim can be processed for payment with some line items denied for payment. The denied line item cannot be resubmitted but it can be appealed. |
| 19 | No longer valid or not active | Mutually exclusive procedure that is not allowed by CCI even if appropriate modifier is present | Effective July 1, 2012, CMS has consolidated the mutually exclusive edit file into the Column 1/Column 2 edit file. The edits previously contained in the mutually exclusive edit file have not been deleted but have been moved to the Column 1/Column 2 correct coding edit file. The procedure is one of a pair of mutually exclusive procedures in the NCCI table coded on the same day, where the use of a modifier is not appropriate. Only the code in column 2 of a mutually exclusive pair is rejected; the column 1 code of the pair is not marked as an edit. | The claim can be processed for payment with some line items rejected. The rejected line items may be corrected and resubmitted but they cannot be appealed. |
| 20 | Both OPPS and non-OPPS edit | Code 2 of a code pair that is not allowed by CCI even if the appropriate modifier is present | This edit occurs when the procedure code is identified as a component of another procedure on the same service date, where the use of a modifier is not appropriate. Often, the column 2 code is a component of a procedure that is billed on the same date as the comprehensive procedure. Only the code in column 2 of a comprehensive and component pair is rejected. This edit is also based on CCI logic. The presence of a modifier will not eliminate this error under any circumstances. EXAMPLE: If 93015 Cardiovascular Stress Test; Physician Supervision, Interpretation and Report, was reported with 93016 Cardiovascular Stress Test; Physician Supervision Only, then 93016 would receive this edit. The result will be a line item rejection. | The claim can be processed for payment with some line items rejected. The rejected line items may be corrected and resubmitted but they cannot be appealed. |
| 21 | OPPS edit | Medical visit on same day as a type T or S procedure without modifier 25 | This edit occurs when a medical visit, an evaluation and management (E&M) service, is billed on the same day as a surgical procedure (either an “S”, significant procedure not discounted, or a “T”, significant procedure eligible for discounting) and modifier 25 is not added to the E&M code. E&M codes are not normally reimbursed on the same day as a surgery or significant procedure. Modifier 25 signals that the physician performed additional services on the visit beyond those associated with the procedure.EXAMPLE:10081 Incision and Drainage of Pilonidal Cyst Complicated, reported with G0402 Initial Preventive Physical Exam; face to face visit, services limited to new beneficiary during the first six months of Medicare enrollment, without modifier 25 would generate edit 021. The result will be the claim is returned to the provider. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 22 | Both OPPS and non-OPPS edit | Invalid modifier | This edit occurs when the modifier is not valid and the revenue code is not RC 0540. It indicates that the two-character modifier associated with the HCPCS code is not valid for the service date or has never been valid according to OCE definitions. NOTE: The invalid modifier edits are suspended for line items with revenue code 0540. EXAMPLE:CMS deleted modifier V8,Infection present, effective April 1, 2012. Any claim that contains modifier V8 with a service date after April 1, 2012 would generate this edit. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 23 | Both OPPS and non-OPPS edit | Invalid date | This edit occurs when the from and through statement covers dates (FL 6) or the service date (FL 45) are invalid or the service date falls outside the from and through dates. This edit terminates the processing of the claim. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 24 | Both OPPS and non-OPPS edit | Date out of OCE range | This edit occurs when the “from” date reported in the statement covers period, FL 6 falls outside the date range for any version of the OCE program (before August 1, 2000). This edit terminates the processing of the claim. The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the FI makes a determination or obtains further information. |
| 25 | Both OPPS and non-OPPS edit | Invalid age | This edit occurs when the age is non-numeric or outside the range of 0-124. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 26 | Both OPPS and non-OPPS edit | Invalid sex | This edit occurs when the sex is non-numeric or outside the range of 0-2. The OCE requires a patient sex of 1 (Male), 2 (Female), or 0 (Unknown). Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 27 | OPPS edit | Only incidental services reported | This edit occurs when all line items on the claim are incidental (service indicator is N), have a line item denial/rejection flag of 0, and/or have a line item action flag of 0. Incidental services are packaged under the OPPS and are paid as part of another primary service or procedure performed. This error is assigned only if all of the following are true: 1. The claim has at least one HCPCS code or a revenue code that is classified as packaged; and 2. The claim has no fee schedule items; and 3. The claim has no HCPCS codes eligible for assignment to any APC; and 4. None of the line items on the claim are denied or rejected (see edit 047).Note: This edit is performed immediately after edit 018. If edit 027 is assigned, no other edits will be performed on these services.Claim Rejection. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 28 | Both OPPS and non-OPPS edit | Code not recognized by Medicare; alternate code for same service may be available | This edit occurs when the procedure code has a “not recognized by Medicare” indicator. It identifies codes that are not reportable to Medicare because Medicare requires an alternate code to be used. Usually the alternate is a HCPCS Level II code. Most, but not all, of the codes in this category have been assigned to the payment status of “E” (non-covered). Line item rejection. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 29 | OPPS edit | Partial hospitalization service for nonmental health diagnosis | This edit occurs when the reason for the visit is not related to mental health. It identifies a partial hospitalization claim that does not have a mental health diagnosis. Partial hospitalization claims must include a mental health diagnosis since this program is for patients who have a profound and disabling mental health condition. Any claim with bill type of 076x (for Community Health Center claims) or bill type 013x with condition code 41 (for hospital outpatient partial hospitalization claims) that does not have a diagnosis in the mental health range will get this edit. The OCE mental health range for ICD-10-CM diagnosis codes is F01?F04, F06.1?F99, G30.0?G30.9, G31.09, G31.1, G31.83, G47.52?G47.53, plus psychological abuse during pregnancy, a large number of “R” codes, signs and symptoms, ?T ? codes for physical and psychological abuse, and numerous ?Z? encounter s, including Z72.810, Child and adolescent antisocial behavior and Z91.5, Personal history of self-harm among others. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 30 | OPPS edit | Insufficient services on day of partial hospitalization | This edit occurs when APC 5853 or and 5863 is present and three or more of the following are not present on the claim: activity therapy HCPCS code G0176, occupational therapy code; G0129, patient education and training; HCPCS code G0410, group psychotherapy, 45-50 minutes in a PHP; and G0411, interactive group psychotherapy, in a PHP.For multiple day claims, this edit will only trigger if edits 32, 33, or 34 have also been activated. This edit applies to outpatient partialhospitalization (bill type 013x with condition code 41) and CommunityMental Health Center (bill type 0761) claims only. training services. Edit 030 isassigned to each day of a partial hospitalization claim where one of the following is true:1. At least one, but less than three, partial hospitalization services are provided on a day. Edit 030 may not appear on a claim, even if the above criteriaare met, if all of thefollowing are true:1. There are more than 3 days of service on the claim. 2. At least 57% (4/7) of the days that the claim spans includedpartial hospitalization services.3. At least 75% of the days that theclaim spans meet the partial hospitalization service criteria listed above. If one of the occupational training codes listed above appears multiple times, or with units greater than one, on a particulardate, that service is counted only once in determining eligibility for edit 030. Each day of a partial hospitalization claim that does not get edit 030 is potentially eligible to receive the partial hospitalizationper diem payment for that day. The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the MAC makes a determination or obtainsfurther information. |
| 31 | No longer valid or not active | Partial hospitalization on same days as electroconvulsive therapy or type T procedure (V1.0-V6.3 only) | This edit identifies a date of service where the patient received electroconvulsive therapy (ECT) or a surgical service (type “T”, subject to multiple procedure discounting) on the same day as partial hospitalization services. The claim will be reviewed to determine if the partial hospitalization day is reasonable and necessary, taking into account the patient’s condition. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only. ECT is identified by APC 00320. The presence of an ECT service, or any service assigned to an APC with payment status of “T”, on any date within a partial hospitalization claim, will generate this error on the claim. This edit applies to V1.0-V6.3 only. The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the FI makes a determination or obtains further information. |
| 32 | No longer valid or not active | Partial hospitalization claim spans three or less days with insufficientservices on at least one of the days (v1.0-v9.3) | This edit combines edit 030 and 031 for partial hospitalization claims with “from” and “through” dates spanning two or three dates of service. For these claims, if one or more of the days qualifies for either edit 030 or 031, then the claim is also assigned edit 032. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only.The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the MAC makes a determination or obtains further information. |
| 33 | No longer valid or not active | Partial hospitalization claim spans more than three days withinsufficient number of days having mental health services (v1.0-v9.3) | This edit identifies a partial hospitalization claim with insufficient mental health services, where the claim spans more than three days. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only. A claim with a claim span of more than three days, where less than four out of seven days (less than 57% of the days in the claim span) contain at least one partial hospitalization service, will be assigned edit 033.In the context of this edit, claim span is defined as the earliest service date to the latest service date. For example, a claim with a “from date” of October 1st, and a “through date” of October 31st, but with services provided only on October 10th-20th , would have a claim span of eleven days in the context of this edit.The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the FI makes a determination or obtains further information. |
| 34 | No longer valid or not active | Partial hospitalization claim spans more than three days with insufficient number of days meeting partial hospitalization criteria (v.0-v9.3) | This edit combines edit 030 and 031 for partial hospitalization claims with “from” and “through” dates spanning more than three days. This edit applies to outpatient partial hospitalization (bill type 13x with condition code 41) and Community Mental Health Center (bill type 761) claims only. This edit applies to any claim that spans more than three days, which does not meet the criteria for edit 033. (If a claim has been assigned edit 033, it is not eligible for edit 034). On the claim there must be an adequate number of days that contain at least one partial hospitalization service, but in addition, at least 75% of those days must also contain the minimum level of partial hospitalization services required to qualify for the per diem payment. (This is the minimum level of services that will not generate edit 030 for the day.) If these conditions are not met, the claim will be assigned edit 034. In the context of this edit, claim span is defined as the earliest service date to the latest service date. For example, a claim with a “from date” of October 1st, and a “through date” of October 31st, but with services provided only on October 10th-20th, would have a claim span of eleven days in the context of this edit. The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the FI makes a determination or obtains further information. |
| 35 | OPPS edit | Only mental health education and training services provided | This edit occurs when only patient education and training services without APC 5853 or 5863. Edit 35 is assigned to any claim where the only services on the claim are classified as mental health education and training services. Edit 35 is not assigned to partial hospitalization claims, and does not require a mental health diagnosis. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 36 | No longer valid or not active | Extensive mental health services provided on day of electroconvulsive therapy or type T procedure (Active V1.0-V6.3 only) | This edit occurs when electroconvulsive therapy or a nonmental healthtype T procedure APC is present on the same day as an extensive mentalhealth service. This edit is similar to partial hospitalization edit031, but applies only to mental health (non-partial hospitalization)claims. ECT is identified by APC 5723. Only procedures assigned to APCs5851, 5852, 5861, or 5862 are considered “extensive” mentalhealth services in the context of this edit.The presence of a paymentstatus “T” service alongside extensive mental health servicesdoes not trigger edit 036 unless the claim is eligible for the mentalhealth per diem cap for that day. That is, where payment for mentalhealth services for a particular service date exceeds the mental healthper diem cap. | A suspended claim is not returned to the provider but will not be processed for payment until the FI/MAC makes a determination orobtainsfurther information. |
| 37 | OPPS edit | Terminated bilateral procedure or terminated procedure with units greater than one | This edit occurs when modifier 52 or 73 is present and an independent or conditional bilateral procedure with modifier 50 is reported, or a procedure with units greater than 1. When a procedure is terminated, the first procedure that was planned should be reported with an appropriate modifier. Any other procedure should not be reported. Terminated procedures are identified with modifier 73. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 38 | OPPS edit | Inconsistency between implanted device or administered substance andimplantation or associated procedure | This edit identifies cases where a claim contains an implanted device with a status indicator of H, U, or APC 987-997 (Implant) is present, but no type S, T, or non-implant type X procedures are present on the claim (v1.0-15.3 only). There is a code with status indicator H or U present, but no type S, T, or J1 procedures are present on the same claim. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 39 | No longer valid or not active | Mutually exclusive procedure that would be allowed by NCCIifappropriatemodifier were present | Effective July 1, 2012, CMS has consolidated the mutually exclusive edit into the column 1/column 2 edits. | The claim can be processed for payment with some line itemsrejected.Therejected line items may be corrected and resubmitted butthey cannotbe appealed. |
| 40 | Both OPPS and non-OPPS edit | Code 2 of a pair that would be allowed by NCCI if appropriate modifiers were present | This edit identifies the column 2 code of a Column1/Column2 Correct Coding edit. It occurs when the procedure is identified as a part of another procedure reported on the claim for the same day, where either no modifier was reported or is not an NCCI modifier. Services that are normally a component of a more comprehensive procedure cannot be billed separately, but must be considered as included in the more comprehensive procedure. Only certain modifiers will override this edit. They are 58, 59, 78, 79, and 91 for Level I. For Level II, they are E1-E4, F1-F9, FA, LC, LD, LT, RC, RT, T1-T9, and TA. EXAMPLE: If 77412 Radiation, Three or More Treatment Areas; Up to 5 MEV was reported with 77402 Radiation,Single Treatment Area; Up to 5 MEV, without the appropriate modifier, 77402 would receive this edit. The result will be a line item rejection of the column 2 code. | The claim can be processed for payment with some line items rejected. The rejected line items may be corrected and resubmitted but they cannot be appealed. |
| 41 | Both OPPS and non-OPPS edit | Invalid revenue code | This edit occurs when the revenue code reported is not on the list of valid UB-04 revenue codes for the patient’s dates of service, or has never been valid, or the claim line was submitted without a revenue code. Effective with the V5.0 OCE, any claim lines which have no HCPCS code and an invalid revenue code are also assigned to payment status “W”. NOTE: In addition to identifying invalid revenue codes, the OCE groups revenue codes into four categories: non-covered, non-allowed, packaged, and other.   Any claim line that contains only revenue codes and charges (i.e., any claim line without a HCPCS code) is slotted by the OCE into one of thee four group aboves. Only Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 42 | OPPS edit | Multiple medical visits on same day with same revenue code withoutcondition code G0 | This edit occurs when multiple medical visits (based on the number of units reported or the number of lines on the claim) are present on the same day with the same revenue code, without condition code G0 to indicate that the visits were distinct and independent of each other. When the revenue center code is the same, multiple medical visits made on the same date of service must be billed with a condition code of G0. If this claim does not have condition code G0, the OCE will identify the highest paying visit, and will flag all other visits with this edit. A medical visit is identified by an evaluation and management HCPCS code. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 43 | OPPS edit | Transfusion of blood product exchange without specification of blood product | This edit occurs when a blood transfusion or exchange is coded but no blood product is coded. There are only a few codes used in the OCE to identify blood administration services. These include CPT codes 36430 Blood Components Indirect Transfusion, 36440 Blood Push Transfusion <= 2 years, 36550, Blood exchange/transfusion, newborn,36555 Blood exchange/transfusion, non-newborn, and 36460 Intrauterine Transfusion. There are over 40 codes used in the OCE to identify blood products. These are in the ranges P9010–P9023, P9031–P9060, and P9070?P9072. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 44 | OPPS edit | Observation revenue code on line item with nonobservation HCPCS code | This edit identifies claim lines containing inappropriately coded observation room services. It occurs when observation RC 0762 is used with a HCPCS code other than observation (99217–99220, 99234–99236, G0378). EXAMPLE: A claim line with charges and RC 0762 which contains CPT code 73120 Xray Hand Two Views, will be assigned to this edit. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 45 | OPPS edit | Inpatient separate procedures not paid | Medicare has established a list of procedures that it believes can only be safely performed in the inpatient setting. The purpose of edit 045 is to identify instances where inpatient only procedures will not trigger a day denial. When included on an outpatient claim, these service will generate edit 018, and all services on that date will be denied. With edit 018, the OCE will deny any service that occurred on the same day as an inpatient only procedure (indicated by payment status indicator “C”). In contrast, assignment of edit 045 results in a line item rejection of only the inpatient procedure. Other services provided on the same date may be reimbursed. Medicare designated a sub-group of inpatient procedures as “Separate Procedures.” Under certain circumstances these procedures trigger edit 045 instead of edit 018. If an inpatient procedure is on the “Separate Procedures” list, edit 045 will be assigned to this procedure as long as there is another service on the same date with a payment status indicator “T”. Otherwise, if no payment status “T” procedure occurs on the same date, edit 018 will be assigned. EXAMPLE: 27005 Incision of hip tendon is considered to be an “inpatient only” procedure and also occurs on the “Separate Procedures” list. In the presence of a type “T” procedure provided on the same day, only CPT code 27005 would be assigned edit 045 and flagged for line item rejection. The result will be a line item rejection. | The claim can be processed for payment with some line items rejected. The rejected line items may be corrected and resubmitted but they cannot be appealed. |
| 46 | Both OPPS and non-OPPS edit | Partial hospitalization condition code 41 not approved for type of bill | This edit identifies incorrect partial hospitalization claims and occurs when TOB code (FL 4) 012X or 014X is present on the claim with condition code 41 in FLs 18-28. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 47 | OPPS edit | Service is not separately payable | This edit will be assigned to all line items with a service indicator of N that are not already denied or rejected. This edit occurs when a claim entirely consists of: 1. One or more line item denials and/or rejections, and 2. One or more line items classified as incidental or packaged. These claim lines include HCPCS codes with payment status indicators of “N”, as well as packaged revenue codes reported with charges only (no HCPCS), also assigned to payment status “N”. Edit 47 is assigned to all lines with status indicator N, or that change from Q to N. EXAMPLE: A claim with HCPCS code 78351 Bone Density Study with Dual Photon Absorptiometry (non-covered service) and a line item with charges only (no HCPCS) for revenue code 0252 Pharmacy Nongeneric Drugs. The line item with charges only and no HCPCS code will receive edit 047. The line with 78351 will get edit 009.The result will be a line item rejection. | The claim can be processed for payment with some line items rejected. The rejected line items may be corrected and resubmitted but they cannot be appealed. |
| 48 | OPPS edit | Revenue center requires HCPCS | The purpose of this edit is to identify claim lines containing charges only (no HCPCS) with revenue codes that are not considered by the OCE to be packaged. If the revenue code is on a list of “non-covered” or “non-allowed” revenue codes, the charges associated with this line will be excluded from any outlier payments or hold harmless adjustment calculations. This edit occurs when TOB code (FL 4) 013X, 074X, 075X, 076X, or 012X or 014X without condition code 41, is reported, the HCPCS code is blank, and the revenue center service indicator is not N or F. This edit is bypassed if the revenue code is 099x, 100x, 210x, 310x, 0500, 0509, 0521, 0522, 0524, 0525, 0527, 0528, 0583, 0637, 0660-0663, 0669, 0905-0907, 0931, 0932, or 0948. See also edit 65.EXAMPLE: Any line item with non-zero charges without an associated HCPCS code which is assigned to RC 0320 General Diagnostic Radiology, for a claim with bill type 0131 will generate edit 048.Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 49 | OPPS edit | Service on same day as inpatient procedure | This edit occurs when the line item occurs on the same day as a service with a status indicator of C. The presence of a service on an outpatient claim which Medicare considers to be “inpatient only” causes Medicare to deny all services provided on the same service date. Services provided on the same date as an “inpatient only” service are all assigned to edit 049, and flagged for line item denial. Since edit 018 initiates the assignment of edit 049, no other edits will be performed on lines with edit 049.EXAMPLE: Any line item with the same service date as any service with payment status “C” which is not on the “Separate Procedures” list (see edit 045) will generate edit 049.The result will be a line item denial. | There may be one or more edits that cause one or more line items to be denied. The claim can be processed for payment with some line items denied for payment. The denied line item cannot be resubmitted but it can be appealed. |
| 50 | Both OPPS and non-OPPS edit | Noncovered based on statutory exclusion | Certain services that are not covered by Medicare due to a statutory requirement have been separated from the other non-covered services and assigned to this edit. This edit occurs when the code is on the “statutory exclusions list” or when RC 0637 is billed without a HCPCS code. EXAMPLE: V5241 Dispensing Fee Monaural Hearing Aid is a non-covered service based on statutory exclusion. Return claim to provider (RTP). | The claim will be returned to the provider for correction. |
| 51 | No longer valid or not active | Multiple observations overlap in time (not activated) | Inactive | Inactive |
| 52 | No longer valid or not active | Observation does not meet minimum hours, qualifying diagnosis and/or T procedure conditions (V3.0-V6.3) | This edit applies to V3.0-V6.3 only. Observation services were eligible for additional payment under the OPPS in certain limited circumstances. These observation services were identified by HCPCS code G0244. This code was only allowed on a hospital outpatient claim if all of the following were true (See edits 056 and 057): 1. One of the diagnoses on the claim had to be related to chest pain, congestive heart failure, or asthma. Medicare has specified a list of diagnoses that correspond to each condition. The diagnosis code can be in any position on the claim. The admit DX is also considered for this requirement. 2. The units associated with G0244 had to be greater than or equal to 8 hours of observation. Less than 8 hours of observation services are not separately payable. 3. There could not be a service with payment status “T” present on the claim with a service date equal to, or one day prior to, the G0244 service date. As of January 1, 2006: Edit 052 is no longer active. However, requirements for separately payable observation services have not changed. Observation services are reported with new HCPCS code G0378 Hospital Observation Services per Hour. Observation services not meeting the hours, diagnosis or type “T” criteria of edit 052 will be packaged, rather than designated as separately payable, but edit 052 will no longer be assigned. EXAMPLE (Prior to January 1, 2006 only): Any claim containing diagnosis code 4281 Left Heart Failure, is present on the claim in any position, along with G0244 with units less than 8 hours will generate edit 052. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 53 | Both OPPS and non-OPPS edit | Codes G0378 and G0379 only allowed with bill type 013X | This edit occurs when codes G0378 and/or G0379 appear on the claimandthe TOB code is not 013X. January 1, 2006 and after: The HCPCScodesG0378 Observation Care by Facility, and G0379 Direct AdmittoObservation, are not allowed on any claim except those with bill type013X.EXAMPLE: A claim with bill type 0341 containing procedure codeG0378 with service date on or after January 1, 2006 will generatethisedit.The result will be a line item rejection. | The claim can be processed for payment with some line items rejected.Therejected line items may be corrected and resubmitted but they cannotbe appealed. |
| 54 | No longer valid or not active | Multiple codes for the same service | Edit 054 identifies two codes that were not allowed to be coded together on the same day. Both codes received the edit. This edit involves only a small set of code pairs describing blood components and occurs when any of the following three pairs of codes appear on the same claim: C1012 and P9033, C1013 and P9031, or C1014 and P9035. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 55 | OPPS edit | Nonreportable for site of service | HCPCS codes beginning with “C” (generally codes representing pass-through devices) is reported and the TOB is not 012X, 013X, or 014X.EXAMPLE: A claim with bill type 0341 along with the following code would receive edit 055 on that claim line: C1760 Vascular Closure Device. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 56 | No longer valid or not active | E/M condition not met and line item date for observation code G0244 is not December 31 or January 1 (Active V4.0-V6.3) | This edit applies to V4.0-V6.3 only. It identifies claims where observation services are reported separately but without the required E/M services, and the service date was not the first day of any calendar year. As of January 1, 2006, edit 056 is no longer active. However, requirements for separately payable observation services have not changed. Observation services are reported with new HCPCS code G0378 Hospital Observation Services Per Hour, and direct admission to observation is reported with new HCPCS code G0379 Direct Admission to Observation. Observation services that do not meet the E/M criteria of edit 056 will be packaged, rather than designated as separately payable, but edit 056 will no longer be assigned. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 57 | OPPS edit | E/M condition not met for observation and line item date for code G0378 is January 1 | There is no E/M or critical care visit the day of or the day preceding the observation or code G0379 is missing, and the date of observation is January 1. Effective January 1, 2006, this edit is applied only to observation services on the first day of January. Previously this edit applied also to observation services provided on the last day of December.EXAMPLE: A claim containing diagnosis code 4281 Left Heart Failure, is present on the claim in any position, along with G0378 with units equal to 24, but the claim does not contain an E/M code with a service date equal to, or one day prior to, the G0378 service date, which is equal to January 1, 2006.The claim will be suspended. | A suspended claim is not returned to the provider but will not be processed for payment until the FI/MAC makes a determination or obtains further information. |
| 58 | OPPS edit | G0379 only allowed with G0378 | This edit identifies claims where HCPCS code G0379 Direct Admit to Observation, is reported on a claim with bill type 013X without code G0378, Hospital Observation Services Per Hour for the same line item date of service, or code G0378 is present with G0379 and OCE edit 57 is assigned. EXAMPLE: A claim containing a line item with HCPCS code G0379 but the claim does not contain a line item with G0378.Return claim to provider (RTP) | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 59 | No longer valid or not active | Clinical trial requires diagnosis code V707 as other than primary diagnosis | This edit identifies claims where clinical trial services are present, but the ICD-9-CM code V707 Examination of Participant in Clinical Trial, is not submitted as the admitting diagnosis or a secondary diagnosis. Clinical trial requires diagnosis code V707 as other than primary diagnosis and are represented by the following HCPCS codes: G0292 Administration of Experimental Drug for Clinical Trial, G0293 Non-Covered Surgical Procedure for Clinical Trial (Effective Before 7/1/03 only) G0294 Non-Covered Procedure for Clinical Trial This edit has been deleted, retroactive to the earliest included version. | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 60 | OPPS edit | Use of modifier CA with more than one procedure not allowed | Edit 060 identifies claims in which modifier CA is used to identify an inpatient-only service performed on an emergency room patient who dies before being admitted or transferred. It cannot be used more than once for the same date on the same claim. Also, units must equal 1 for any service with the modifier CA. Therefore, this edit occurs when modifier CA is present on more than one line with service indicator C and the same line item date of service, or modifier CA is submitted on a line with multiple units. EXAMPLE: A claim containing HCPCS code 62258, Removal of Complete Cerebrospinal Fluid Shunt System with modifier CA and 2 units of service would generate edit 060. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 61 | Both OPPS and non-OPPS edit | Service can only be billed to the DMERC | This edit occurs when a claim contains a HCPCS code that has a status indicator of Y (DME only). It identifies codes representing non-implantable durable medical equipment that should be billed separately to the regional carrier (DMERC). EXAMPLE: A4231 Infusion Insulin Pump with Needle billed to an FI would generate edit 061. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 62 | OPPS edit | Code not recognized by OPPS; alternate code for same service may be available | This edit occurs when a claim contains a code that is not allowed for OPPS billing. It identifies codes that are not recognized by Medicare under the OPPS. Alternate, acceptable codes, usually Level II HCPCS codes, may be available for the same service. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 63 | No longer valid or not active | This OT code only billed on partial hospitalization claims | This edit occurs when a claim for other than a partial hospitalization program contains HCPCS code G0129. G0129 is only allowed on partial hospitalization program claims. This edit identifies occupational therapy services on a non-partial hospitalization claim (for example, a standard bill type 13X with no condition code 41). EXAMPLE: G0129 Occupational Therapy billed on a standard outpatient claim with bill type 131 without condition code 41 added to the claim would generate edit 063. Return claim to provider (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 64 | No longer valid or not active | AT service not payable outside the partial hospitalization program | This edit occurs when a claim for other than a partial hospitalization program contains HCPCS code G0176. G0176 is only allowed on partial hospitalization program claims. It identifies activity therapy services on a non-partial hospitalization claim (for example, a standard bill type 131 with no condition code 41). EXAMPLE: G0176 Activity Therapy billed on a standard outpatient claim with bill type 131 without condition code 41 added to the claim would generate edit 064. Line item rejection. | The claim can be processed for payment with some line items rejected. The rejected line items may be corrected and resubmitted but they cannot be appealed. |
| 65 | Both OPPS and non-OPPS edit | Revenue code not recognized by Medicare | This edit occurs when a claim contains a revenue code that Medicare does not recognize: 100X, 210X, 310X, 0500, 0509, 0583, 0660-0663, 0669, 0905-0907, 0931, or 0932. Line items with these revenue codes are rejected for payment by Medicare, regardless of whether a HCPCS code appears on the line. See also edit 48. EXAMPLE: Revenue code 0905 Psychiatric/Psychological Treatments of Intensive OP Services – Psychiatric is not recognized by Medicare and would generate edit 065 on a claim. Line item rejection. | Lines containing these revenue codes will be rejected and the remainder of the claim will be processed. Providers can submit adjustment bills with different revenue codes. |
| 66 | OPPS edit | Code requires manual pricing | This edit suspends the line item with HCPCS code C9399 so that the FI/MAC can manually price the drug, biological, or radiopharmaceutical. Services provided after FDA approval but prior to designation of a new HCPCS code are billed using HCPCS code C9399, Unclassified Drugs or Biologicals. This code causes a claim suspension so that the service can be manually priced based on 95% of the AWP. Supporting information including National Coverage Determination (NCD) code, units and date of service may be required in the remarks section of the claim. | The claim can be processed for payment. The drug or biological will remain suspended until the MAC prices and processes it. |
| 67 | Both OPPS and non-OPPS edit | Service provided prior to FDA approval | This edit occurs when any new drug or biological which is provided after designation of a new HCPCS code but prior to FDA approval is flagged with edit 067. EXAMPLE: HCPCS code C9224, Injection Galsulfase, received FDA approval on May 31, 2005. If coded with service dates prior to that date, the claim would receive edit 067. The service line will be denied. | The claim will be processed and the procedure, service or item that this edit applies to will be denied. |
| 68 | Both OPPS and non-OPPS edit | Service provided prior to prior to date of National Coverage Determination (NCD) approval | This edit occurs when the date that a procedure, service or item was performed or administered is prior to the effective date of coverage that is contained within the NCD. EXAMPLE: HCPCS code 78459 Myocardial Imaging, PET, Metabolic Evaluation received NCD approval on January 30, 2005. If coded with service dates prior to that date, the claim would receive edit 068. | Line item denial. |
| 69 | Both OPPS and non-OPPS edit | Service provided outside approval period | This edit occurs when the date that a procedure, service or item was performed or administered is outside the range of dates contained within an approval or limited coverage period. | Line Item Denial |
| 70 | OPPS edit | CA modifier requires patient discharge status indicating expired or transferred | This edit occurs when modifier CA has been reported with an inpatient-only procedure code on an outpatient claim. Services which have been designated as “inpatient only” can be reimbursed when performed in the emergency room when the patient dies prior to admission or transfer. The patient status indicator (FL 22) must be 20, Expired, or 02, 05, 43, or 66, for transfers for the inpatient-only procedure to be paid under OPPS. EXAMPLE: HCPCS code 27470 Repair of Femur Without Graft, is an inpatient only procedure. If performed in an emergency room on an outpatient basis and the patient dies prior to admission, the claim must include modifier CA and status code 20. Otherwise, edit 069 will be generated. The claim will be returned to the provider for correction (RTP). | Correct the error(s) and resubmit |
| 71 | No longer valid or not active | Claims lacks required device code(s) | This edit occurs when a procedure has been reported that must have a HCPCS device code(s). Note that this edit is bypassed when modifier 52, 73, or 74 is present. Hospitals paid under the OPPS that report procedure codes that require the use of a device must also report the applicable HCPCS code and charges for the devices that are used to perform the procedure. Device coding is necessary so that the OPPS payment for these procedures will be correct in future years. EXAMPLE: HCPCS code 92982 Coronary Artery Dilation reported without HCPCS codes C1725, C1874, C1876 or C1885 would generate edit 071. The claim will be returned to the provider for correction (RTP). | The provider should consult the list of procedure-to-device code edits and resubmit the claim once the problem(s) is/are corrected. |
| 72 | Both OPPS and non-OPPS edit | Services not billable to the Fiscal Intermediary/Medicare Administrative Contractor | This edit occurs when a procedure code was reported that should not be reported on claims to a fiscal intermediary or on facility claims to a Medicare Administrative contractor. The status indicator of the code is M. Generally this edit relates to IV fusion, chemotherapy and chemotherapy assessment services provided by the physician. EXAMPLE: Generally, codes that trigger this edit are designed to be used by physicians. If HCPCS code 88291, Cytogenics and Molecular Cytogenics Interpretation and Report, for example, is reported on a hospital outpatient claim, rather than on the physician claim, edit 072 would be generated.The claim will be returned to the provider for correction (RTP). | The provider should consult the list of procedure-to-device code edits and resubmit the claim once the problem(s) is/are corrected. |
| 73 | OPPS edit | Incorrect billing of blood and blood products | If an OPPS provider pays for the actual blood or blood product itself, in addition to paying for processing and storage costs when blood or blood products are supplied by either a community blood bank or the OPPS provider’s own blood bank, the OPPS provider must separate the charge for the blood product(s) from the charge for processing and storage services. The OPPS provider reports charges for the blood or blood product itself using revenue code series 038X with the appropriate blood product HCPCS code and HCPCS modifier BL. The OPPS provider reports charges for processing and storage services on a separate line using RC 0390, Blood Storage and Processing, General Classification, or 0399, Storage and Processing, Other, with the appropriate blood product HCPCS code and HCPCS modifier BL.Whenever an OPPS provider reports a charge for blood or blood products using revenue code series 038X, the OPPS provider must also report a charge for processing and storage services on a separate line using RC 0390 or 0399. Further, the same date, units, HCPCS code, and modifier BL must be reported on both lines.The OCE returns to providers any claim that reports a charge for blood or blood products using RC 038X without a separate line for processing and storage services using RC 0390 or 0399 and both lines must include the same line item date of service, units, and HCPCS code accompanied by modifier BL. EXAMPLE: If P9010, Blood, whole for transfusion is billed with revenue code 381, and there is not another line on the same claim with matching date, units, HCPCS code and revenue code 39X, or if there is a matching line but both claim lines don’t include modifier BL, then this edit would be generated. The claim will be returned to the provider for correction (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 74 | Both OPPS and non-OPPS edit | Units greater than one for bilateral procedure billed with modifier 50. | This edit ocurs when any code on the Conditional or Independent bilateral list is submitted with modifier 50 and the units of service are greater than one on the same line. EXAMPLE: If 29345, Application of Long Leg Cast (Thigh to Toes), is billed with modifier 50, 2 units, and a service date on or after 10/1/2006, then this edit would be generated.The claim will be returned to the provider for correction (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 75 | No longer valid or not active | Incorrect billing of modifer FB or FC | This edit occurs when modifier FB (item provided without cost to provider, supplier or practitioner) or FC (Partial credit received for replaced device) is appended to the wrong code on a claim. Modifier FB or FC should be reported only with procedures that have a status indicator of S, T, V, or X. EXAMPLE: If 90655, (influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use) is billed with modifier FB, then this edit would be generated. The claim will be returned to the provider for correction (RTP). | The provider should resubmit the claim once the problem(s) is/are corrected. |
| 76 | OPPS edit | Trauma response critical care code without revenue code 068X and CPT 99291 | This edit occurs when the trauma response critical care HCPCS code G0390 (trauma response team activation associated with hospital critical care service) is not reported under revenue code 068X and/or critical care CPT code 99291 (evaluation/management of critically ill or critically injured patient, first 30-74 minutes) is not reported on the same date of service. EXAMPLE: If G0390 is reported with RC 0681 on one day of service (for example January 1, 2007) and is billed with CPT code 99291 (evaluation/management of critically ill or critically injured patient, first 30-74 minutes) on another day of service (for example January 2, 2007), then this edit would be generated. The service line will be rejected. | The claim can be processed for payment with some line items rejected. The rejected line items may be corrected and resubmitted but they cannot be appealed. |
| 77 | No longer valid or not active | Claim lacks allowed procedure code | This edit occurs when a device code has been reported that must have an associated allowed procedure. Note that this edit is bypassed when modifier 52, 73, or 74 is present. EXAMPLE: HCPCS code C1820 Generator Neurostimulator (Implantable), with Rechargeable Battery and Charging System reported without HCPCS codes 61885, 63685, or 64590 would generate edit 077. The claim will be returned to the provider for correction (RTP). | The provider should consult the list of device-to-procedure code edits and resubmit the claim once the problem(s) is/are corrected. |
| 78 | No longer valid or not active | Claim lacks required radiolabeled product | Effective January 1, 2008, this edit occurs when a CPT code for a diagnostic nuclear medicine procedure (CPT codes 78000–78999) is reported on a claim without a corresponding HCPCS code for a diagnostic radiopharmaceutical. This edit is not date specific; the radiopharmaceutical does not need to be on the same date as the nuclear medicine service. Also, there is not a one-to-one correspondence between specific nuclear medicine procedures and specific radiopharmaceuticals. If a nuclear medicine service receives edit 78, adding any diagnostic radiopharmaceutical on the list will correct the edit. The claim will be returned to the provider for correction (RTP). | Add the HCPCS code for the radiolabeled product. |
| 79 | OPPS edit | Incorrect billing of revenue code with HCPCS code | Effective for dates of service on or after October 1, 2008, only packed red cells should be reported with revenue code 0381 and only whole blood should be reported withb revenue code 0382. The following HCPCS code should be reported with revenue code 0381: P9016, P9021, P9022, P9038, P9039, P9040, P9051, P9054, P9057, and P9058. The following HCPCS code should be reported with revenue code 0382: P9010, P9051, P9054, P9056. A split unit, HCPCS code P9011, should be reported with revenue code 0389. Claim will be returned to the provider. | Correct revenue codes and resubmit. |
| 80 | OPPS edit | Mental health code not approved for partial hospitalization program | Partial hospitalization program (PHP) claims are reported with TOB 013X and condition code 41, Partial hospitalization. There are two sets of CPT codes that are specific to “Office or Other Outpatient Facility” and to “Inpatient, Partial Hospital, or Residential Care Facility” based on the titles and instructions in the CPT manual. The following codes have been identified as not appropriate for reporting services on PHP claims: 0362T, 0373T, 90839, 90849, 90853, 90849, 90899, 90862, 96112, 96156,96158, 96164, 96167, 97151–97158, G0451. Claim will be returned to the provider. |
