List of I-OCE (Outpatient code edit) edits Part 2

Edit NumberEdit Hospital TypeEdit DescriptionEdit Result/Claim DispositionProvider Action/Response
81OPPS editMental health service not payable outside the partial hospitilization programThis 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.
82OPPS editCharge 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.
83Both OPPS and non-OPPS editService provided on or after effective date of NCD non-coverageThis 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.
84OPPS editClaim lacks required primary codeAdd-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
85No longer valid or not activeClaim lacks required device code or required procedure codeCode 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
86OPPS editManifestation code not allowed as principal diagnosisA 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
87OPPS editSkin 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.
88OPPS editFQHC payment code not reported for FQHC claimFQHC 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 G0466G0470. Correct and resubmit
89OPPS editFQHC claim lacks required qualifying visit codeFQHC 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 G0466G0470 must be reported with a qualifying
visitcode.Correct and resubmit.
90OPPS editIncorrect revenue code reported for FQHC payment codeFQHC payment code not reported with revenue code 0519, 052X or
0900.Return to Provider
G0466G0468 must be reported with rev code 052X or 0519. G0469 and
G0470 must be reported with rev code 0900 or 0519.
91OPPS editItem or service not covered under FQHC PPS or RHCA 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.
92OPPS editDevice-dependent procedure reported without device codeA procedure from the list of device-dependent procedures is reported
without a device code.
Add the device code and resubmit.
93OPPS editCorneal tissue processing reported without cornea transplant procedureCorneal tissue processing HCPCS (V2785) is reported and there is
nocorneal transplant procedure present for the same service date.
Correct and resubmit
94No longer valid or not activeBiosimilar HCPCS reported without biosimilar modifierA biosimilar HCPCS code is reported on the claim without its
corresponding biosimilar manufacturing modifier.
Add the modifier and resubmit
95OPPS editPartial 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
96No longer valid or not activePartial hospitalization interim claim from and through dates must span
more than 4 days
RTPResubmit with correct time span.
97No longer valid or not activePartial hospitalization services are required to be billed weeklyRTPResubmit with the correct date of service and time span.
98OPPS editClaim with pass-through device, drug or biological lacks required procedureRTPResubmit with the procedure code
99OPPS editClaim 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.
100OPPS editClaim 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

 

101OPPS editItem or service with modifier PN not allowed under PFSModifier 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
102OPPS editModifier pairing not allowed on the same lineA 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.
103No longer valid or not activeModifier reported prior to FDA approval dateA modifier is reported before its activation date for reportingCheck FDA activation date and correct.
104OPPS editService not eligible for all-inclusive rateAn RHC claim (71x) is reported with a line containing the CG modifier.Remove the CG modifier and resubmit.
105OPPS editClaim reported with pass-through device prior to FDA approval for the procedureA 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.
106Both OPPS and non-OPPS editAdd-on code reported without required primary procedure codeA 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
107Both OPPS and non-OPPS editAdd-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
108Both OPPS and non-OPPS editAdd-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
109OPPS editCode 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
110Both OPPS and non-OPPS editService provided prior to initial marketing dateThe 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.
111Both OPPS and non-OPPS editService 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.
112Both OPPS and non-OPPS editInformation 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
113Both OPPS and non-OPPS editSupplementary or additional code not allowed as principal diagnosisThe 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.
114Both OPPS and non-OPPS editItem or service not allowed with modifier CSModifier 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.
115Both OPPS and non-OPPS editCOVID-19 lab add-on code reported without required primary procedureHCPCS 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.
116Both OPPS and non-OPPS editOpioid 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.
117OPPS editToken charge less than $1.01 billed by providerA 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.
118Both OPPS and non-OPPS editInvalid bill typeA 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.
119Both OPPS and non-OPPS editInvalid claim processing receipt dateThe 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.
120Both OPPS and non-OPPS editIncorrect reporting of modifier PTA claim is submitted with only one procedure from the designated
surgical ranges (1000069999)or (0000T9999T) 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.

 

 

121OPPS editNon-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.
122OPPS edit340B-acquired drug modifier(s) reported inappropriatelyPass-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.
123Both OPPS and non-OPPS editModifier used after CMS termination dateThe 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.
124Both OPPS and non-OPPS editHCPCS reported after CMS termination dateThe 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.
125OPPS editIncorrect billing of IMRT planning and deliveryThis 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.
126Both OPPS and non-OPPS editIncorrect reporting of telehealth modifierA 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.
127Both OPPS and non-OPPS editService not allowed for Part B Inpatient ClaimThe 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.

 

 

 

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