Medicare Code Editor Definitions of Medicare Code Edits v31.0 October 2013 PBL-011 October 2013 Table of Contents About this document .......................................................................................... v Chapter 1: Edit code lists .............................................................................. 7 1. Invalid diagnosis or procedure code ...................................................................................... 7 2. E-code as principal diagnosis ................................................................................................ 7 3. Duplicate of PDX ................................................................................................................... 8 4. Age conflict ............................................................................................................................ 8 Newborn diagnoses ............................................................................................................ 8 Pediatric diagnoses (age 0 through 17) ............................................................................ 13 Maternity diagnoses (age 12 through 55) ......................................................................... 14 Adult diagnoses (age 15 through 124) .............................................................................. 34 5. Sex conflict .......................................................................................................................... 36 Diagnoses for females only ............................................................................................... 36 Procedures for females only ............................................................................................. 63 Diagnoses for males only .................................................................................................. 68 Procedures for males only ................................................................................................ 71 6. Manifestation code as principal diagnosis ........................................................................... 73 Manifestations not allowed as principal diagnosis ............................................................ 73 7. Non-specific principal diagnosis .......................................................................................... 78 8. Questionable admission ...................................................................................................... 78 Questionable admission - principal diagnosis only ........................................................... 78 9. Unacceptable principal diagnosis ........................................................................................ 78 Unacceptable principal diagnoses .................................................................................... 79 10. Non-specific O.R. procedure ............................................................................................. 95 11. Non-covered procedure ..................................................................................................... 95 Non-covered procedures ................................................................................................... 95 Open biopsy check .................................................................................................................. 98 13. Bilateral procedure............................................................................................................. 98 Bilateral procedure codes ................................................................................................. 98 14. Invalid age ......................................................................................................................... 99 15. Invalid sex .......................................................................................................................... 99 16. Invalid discharge status ..................................................................................................... 99 17. Limited coverage ............................................................................................................. 100 Limited coverage ............................................................................................................. 101 18. Wrong procedure performed ........................................................................................... 101 Wrong procedure performed ........................................................................................... 101 19. Procedure inconsistent with length of stay ..................................................................... 102 Procedure inconsistent with length of stay ...................................................................... 102 Chapter 2: Code list changes .................................................................... 103 Changes to existing edits ...................................................................................................... 103 Medicare Code Editor Definitions of Medicare Code Edits Page iii Table of Contents Index .................................................................................................. 105 Medicare Code Editor Definitions of Medicare Code Edits Page iv 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-9-CM code lists. The coding edit information in this manual is effective from 10/01/2013 to 09/30/2014. Medicare Code Editor Definitions of Medicare Code Edits Page v Chapter 1: Edit code lists Following is a list of current edits described in this chapter. 1. Invalid diagnosis or procedure code 2. E-code 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 14. Invalid age 15. Invalid sex 16. Invalid discharge status 17. Limited coverage 18. Wrong procedure performed 19. Procedure inconsistent with length of stay 1. Invalid diagnosis or procedure code The Medicare Code Editor checks each diagnosis including the admitting diagnosis and each procedure against a table of valid ICD-9-CM codes. If an entered code does not agree with any code on the internal list, it is assumed to be invalid or that the 4th or 5th digit of the code is invalid or missing. 2. E-code as principal diagnosis For a list of all valid ICD-9-CM codes, see volumes 2 (diseases) and 3 (procedures) of the International Classification of Diseases, 9th Revision, Fourth Edition, Clinical Modification (ICD-9- CM). E-codes are ICD-9-CM codes beginning with the letter E. They describe the circumstance causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. For a list of all E-codes, see volume 2 (diseases) of the International Classification of Diseases, 9th Revision, Fourth Edition, Clinical Modification (ICD-9-CM). Medicare Code Editor Definitions of Medicare Code Edits Page 7 Edit code lists 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 diagnoses 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 syndrome, 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-9-CM diagnosis codes with corresponding English descriptions for each of the age categories described above.