Definitions of Medicare Code Edits DRAFT ICD-10 VERSION Software version 27.0 R1 PBL–031 September 2011 Manual updated March 2012 Document number PBL–031 September 2011 ii Definitions of Medicare Code Edits September 2011 About this document THE MEDICARE CODE EDITOR (MCE) detects and reports errors in the coding claims data. This manual contains a description of each coding edit with corresponding ICD-10-CM and ICD-10-PCS code lists which were published in December 2010. The coding edit information in this manual is effective from 10/01/2010 to 09/30/2011. However it is not intended to be used to process claims as the ICD- 10 code set will not be mandated for use until October 1, 2013. September 2011 iii iv Definitions of Medicare Code Edits September 2011 Contents Preface About this document iii Chapter 1 Edit code lists 1.3 1. Invalid diagnosis or procedure code 1.4 2. External causes of morbidity codes as principal diagnosis 1.4 3. Duplicate of PDX 1.4 4. Age conflict 1.4 5. Sex conflict 1.58 6. Manifestation code as principal diagnosis 1.161 7. Non-specific principal diagnosis 1.166 8. Questionable admission 1.166 9. Unacceptable principal diagnosis 1.167 10. Non-specific O.R. procedure 1.184 11. Non-covered procedure 1.184 12. Open biopsy check 1.191 13. Bilateral procedure 1.191 14. Invalid age 1.191 15. Invalid sex 1.191 16. Invalid discharge status 1.191 17. Limited coverage 1.192 18. Wrong procedure performed 1.193 Chapter 2 Code list changes 2.3 September 2011 Contents v vi Definitions of Medicare Code Edits September 2011 Chapter 1 1Edit code lists Contents Edit code lists 1.3 1. Invalid diagnosis or procedure code 1.4 2. External causes of morbidity codes as principal diagnosis 1.4 3. Duplicate of PDX 1.4 4. Age conflict 1.4 5. Sex conflict 1.58 6. Manifestation code as principal diagnosis 1.161 7. Non-specific principal diagnosis 1.166 8. Questionable admission 1.166 9. Unacceptable principal diagnosis 1.167 10. Non-specific O.R. procedure 1.184 11. Non-covered procedure 1.184 12. Open biopsy check 1.191 13. Bilateral procedure 1.191 14. Invalid age 1.191 15. Invalid sex 1.191 16. Invalid discharge status 1.191 17. Limited coverage 1.192 18. Wrong procedure performed 1.193 1.2 Definitions of Medicare Code Edits September 2011 Chapter 1 Edit code lists BELOW IS A LIST of edits described in this chapter. 1. Invalid diagnosis or procedure code 2. External causes of morbidity codes as principal diagnosis 3. Duplicate of PDX 4. Age conflict 5. Sex conflict 6. Manifestation code as principal diagnosis 7. Non-specific principal diagnosis (Discontinued as of 10/01/07) 8. Questionable admission 9. Unacceptable principal diagnosis 10. Non-specific O.R. procedure (Discontinued as of 10/01/07) 11. Non-covered procedure 12. Open biopsy check (Discontinued as of 10/01/10) 13. Bilateral procedure (Discontinued as of 10/01/13) 14. Invalid age 15. Invalid sex 16. Invalid discharge status 17. Limited coverage 18. Wrong procedure performed September 2011 Edit code lists 1.3 1. Invalid1. diagnosis Invalid or diagnosis procedure code or The Medicare Code Editor checks each diagnosis including the admit- procedure code ting 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. For a list of all valid ICD-10-CM and ICD-10-PCS codes, see the International Classification of Diseases list. 2. External causes of morbidity codes as 2. Externalprincipal causes diagnosis of External causes of morbidity codes are ICD-10-CM codes beginning morbidity codes as principal with the letter V through Y. They describe the circumstance causing diagnosis an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. For a list of all external causes of morbidity codes, see the Interna- tional Classification of Diseases list. 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 the above 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 diagno- ses in the program: ◆ Newborn. Age of 0 years; a subset of diagnoses intended only for newborns and neonates (e.g., fetal distress, perinatal jaundice). ◆ Pediatric. Age range is 0–17 years inclusive (e.g., Reye’s syn- drome, routine child health exam). ◆ Maternity. Age range is 12–55 years inclusive (e.g., diabetes in pregnancy, antepartum pulmonary complication). ◆ Adult. Age range is 15–124 years inclusive (e.g., senile delirium, mature cataract). The following pages contain lists of ICD-10-CM diagnosis codes with corresponding English descriptions for each of the age categories described above. 1.4 Definitions of Medicare Code Edits September 2011 Newborn diagnoses A33 Tetanus neonatorum D807 Transient hypogammaglobulinemia of infancy E71511 Neonatal adrenoleukodystrophy E8411 Meconium ileus in cystic fibrosis H04531 Neonatal obstruction of right nasolacrimal duct H04532 Neonatal obstruction of left nasolacrimal duct H04533 Neonatal obstruction of bilateral nasolacrimal duct H04539 Neonatal obstruction of unspecified nasolacrimal duct N470 Adherent prepuce, newborn P000 Newborn affected by maternal hypertensive disorders P001 Newborn aff by maternal renal and urinary tract diseases P002 Newborn affected by maternal infec/parastc diseases P003 Newborn affected by oth maternal circ and resp diseases P004 Newborn affected by maternal nutritional disorders P005 Newborn (suspected to be) affected by maternal injury P006 Newborn affected by surgical procedure on mother P007 Newborn affected by oth medical procedures on mother, NEC P0081 Newborn affected by periodontal disease in mother P0089 Newborn affected by oth maternal conditions P009 Newborn affected by unsp maternal condition P010 Newborn (suspected to be) affected by incompetent cervix P011 Newborn (suspected to be) affected by premature ROM P012 Newborn (suspected to be) affected by oligohydramnios P013 Newborn (suspected to be) affected by polyhydramnios P014 Newborn (suspected to be) affected by ectopic pregnancy P015 Newborn (suspected to be) affected by multiple pregnancy P016 Newborn (suspected to be) affected by maternal death P017 Newborn affected by malpresentation before labor P018 Newborn affected by oth maternal complications of pregnancy P019 Newborn affected by maternal complication of pregnancy, unsp P020 Newborn (suspected to be) affected by placenta previa P021 Newborn affected by oth placental separation and hemorrhage P0220 Newborn aff by unsp morpholog and functn abnlt of placenta P0229 Newborn aff by oth morpholog and functn abnlt of placenta P023 Newborn affected by placental transfusion syndromes P024 Newborn (suspected to be) affected by prolapsed cord P025 Newborn affected by oth compression of umbilical cord P0260 Newborn affected by unsp conditions of umbilical cord P0269 Newborn affected by oth conditions of umbilical cord P027 Newborn (suspected to be) affected by chorioamnionitis P028 Newborn affected by oth abnormalities of membranes P029 Newborn affected by abnormality of membranes, unsp P030 Newborn affected by breech delivery and extraction P031 NB aff by oth malpresent, malpos & disproprtn dur labr & del P032 Newborn (suspected to be) affected by forceps delivery P033 Newborn affected by delivery by vacuum extractor P034 Newborn (suspected to be) affected by Cesarean delivery P035 Newborn (suspected to be) affected by precipitate delivery P036 Newborn affected by abnormal uterine contractions P03810 NB aff by abnlt in fetl heart rate or rhythm bef onset labor P03811 NB aff by abnlt in fetal heart rate or rhythm during labor P03819 NB aff by abnlt in fetl hrt rate or rhythm, unsp time onset P0382 Meconium passage during delivery P0389 Newborn affected by oth complications of labor and delivery P039 Newborn affected by complication of labor and delivery, unsp P040 NB aff by matern anesth and analgesia in preg, labor and del P041 Newborn affected by oth maternal medication P042 Newborn affected by maternal use of tobacco P043 Newborn affected by maternal use of alcohol P0441 Newborn affected by maternal use of cocaine P0449 Newborn affected by maternal use of drugs of addiction P045 Newborn aff by maternal use of nutritional chemical substnc P046 Newborn aff by maternal exposure to environ chemical substnc P048 Newborn affected by oth maternal noxious substances P049 Newborn affected by maternal noxious substance, unsp September 2011 Edit code lists 1.5 Newborn diagnoses P0500 Newborn light for gestational age, unspecified weight P0501 Newborn light for gestational age, less than 500 grams P0502 Newborn light for gestational age, 500-749 grams P0503 Newborn light for gestational age, 750-999 grams P0504 Newborn light for gestational age, 1000-1249 grams P0505 Newborn light for gestational age, 1250-1499 grams P0506 Newborn light for gestational age, 1500-1749 grams P0507 Newborn light for gestational age, 1750-1999 grams P0508 Newborn light for gestational age, 2000-2499 grams P0510 Newborn small for gestational age, unspecified weight P0511