Definitions of Medicare Code Edits - CMS

1 Definitions of Medicare code EditsDRAFT ICD-10 VERSIONS oftware version R1 PBL 031 September 2011 Manual updated March 2012ii Definitions of Medicare code EditsSeptember 2011 Document number PBL 031 September 2011 iiiSeptember 2011 About this documentTHE 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, Definitions of Medicare code EditsSeptember 2011 Contents vSeptember 2011 ContentsPrefaceAbout this document iiiChapter 1 Edit code lists Invalid diagnosis or procedure code External causes of morbidity codes as principal diagnosis Duplicate of PDX Age conflict Sex conflict Manifestation code as principal diagnosis Non-specific principal diagnosis Questionable admission Unacceptable principal diagnosis Non-specific procedure Non-covered procedure Open biopsy check Bilateral procedure Invalid age Invalid sex Invalid discharge status Limited coverage Wrong procedure performed 2 code list changes Definitions of Medicare code EditsSeptember 2011

2 Chapter 11 Edit code Definitions of Medicare code EditsSeptember 2011 ContentsEdit code lists Invalid diagnosis or procedure code External causes of morbidity codes as principal diagnosis Duplicate of PDX Age conflict Sex conflict Manifestation code as principal diagnosis Non-specific principal diagnosis Questionable admission Unacceptable principal diagnosis Non-specific procedure Non-covered procedure Open biopsy check Bilateral procedure Invalid age Invalid sex Invalid discharge status Limited coverage Wrong procedure performed Edit code lists 2011 Chapter 1 Edit code listsBELOW IS A LIST of Edits described in this diagnosis or procedure causes of morbidity codes as principal of code as principal principal diagnosis (Discontinued as of 10/01/07) principal procedure (Discontinued as of 10/01/07) biopsy check (Discontinued as of 10/01/10) procedure (Discontinued as of 10/01/13) discharge procedure Definitions of Medicare code EditsSeptember 20111.

3 Invalid diagnosis or procedure codeThe Medicare code Editor checks each diagnosis including the admit-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 External causes of morbidity codes as principal diagnosisExternal causes of morbidity codes are ICD-10-CM codes beginning with the letter V through Y. They describe the circumstance causing an injury, not the nature of the injury, and therefore should not be used as a principal diagnosis. For a list of all external causes of morbidity codes, see the Interna-tional Classification of Diseases Duplicate of PDXW henever a secondary diagnosis is coded the same as the principal diagnosis, the secondary diagnosis is identified as a duplicate of the principal diagnosis.

4 4. Age conflictThe 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 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 ( , fetal distress, perinatal jaundice). Pediatric. Age range is 0 17 years inclusive ( , Reye s syn-drome, routine child health exam). Maternity. Age range is 12 55 years inclusive ( , diabetes in pregnancy, antepartum pulmonary complication).

5 Adult. Age range is 15 124 years inclusive ( , 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 External causes of morbidity codes as principal diagnosis1. Invalid diagnosis or procedure code Edit code lists 2011 Newborn diagnosesA33 Tetanus neonatorumD807 Transient hypogammaglobulinemia of infancyE71511 Neonatal adrenoleukodystrophyE8411 Meconium ileus in cystic fibrosisH04531 Neonatal obstruction of right nasolacrimal ductH04532 Neonatal obstruction of left nasolacrimal ductH04533 Neonatal obstruction of bilateral nasolacrimal ductH04539 Neonatal obstruction of unspecified nasolacrimal ductN470 Adherent prepuce.

6 NewbornP000 Newborn affected by maternal hypertensive disordersP001 Newborn aff by maternal renal and urinary tract diseasesP002 Newborn affected by maternal infec/parastc diseasesP003 Newborn affected by oth maternal circ and resp diseasesP004 Newborn affected by maternal nutritional disordersP005 Newborn (suspected to be) affected by maternal injuryP006 Newborn affected by surgical procedure on motherP007 Newborn affected by oth medical procedures on mother, NECP0081 Newborn affected by periodontal disease in motherP0089 Newborn affected by oth maternal conditionsP009 Newborn affected by unsp maternal conditionP010 Newborn (suspected to be) affected by incompetent cervixP011 Newborn (suspected to be) affected by premature ROMP012 Newborn (suspected to be) affected by oligohydramniosP013 Newborn (suspected to be) affected by polyhydramniosP014 Newborn (suspected to be) affected by ectopic pregnancyP015 Newborn (suspected to be) affected by multiple pregnancyP016 Newborn (suspected to be) affected by maternal deathP017 Newborn affected by malpresentation before laborP018 Newborn affected by oth maternal complications of pregnancyP019 Newborn affected by maternal complication of pregnancy, unspP020 Newborn (suspected to be)

7 Affected by placenta previaP021 Newborn affected by oth placental separation and hemorrhageP0220 Newborn aff by unsp morpholog and functn abnlt of placentaP0229 Newborn aff by oth morpholog and functn abnlt of placentaP023 Newborn affected by placental transfusion syndromesP024 Newborn (suspected to be) affected by prolapsed cordP025 Newborn affected by oth compression of umbilical cordP0260 Newborn affected by unsp conditions of umbilical cordP0269 Newborn affected by oth conditions of umbilical cordP027 Newborn (suspected to be) affected by chorioamnionitisP028 Newborn affected by oth abnormalities of membranesP029 Newborn affected by abnormality of membranes, unspP030 Newborn affected by breech delivery and extractionP031NB aff by oth malpresent, malpos & disproprtn dur labr & delP032 Newborn (suspected to be) affected by forceps deliveryP033 Newborn affected by delivery by vacuum extractorP034 Newborn (suspected to be) affected by Cesarean deliveryP035 Newborn (suspected to be)

8 Affected by precipitate deliveryP036 Newborn affected by abnormal uterine contractionsP03810NB aff by abnlt in fetl heart rate or rhythm bef onset laborP03811NB aff by abnlt in fetal heart rate or rhythm during laborP03819NB aff by abnlt in fetl hrt rate or rhythm, unsp time onsetP0382 Meconium passage during deliveryP0389 Newborn affected by oth complications of labor and deliveryP039 Newborn affected by complication of labor and delivery, unspP040NB aff by matern anesth and analgesia in preg, labor and delP041 Newborn affected by oth maternal medicationP042 Newborn affected by maternal use of tobaccoP043 Newborn affected by maternal use of alcoholP0441 Newborn affected by maternal use of cocaineP0449 Newborn affected by maternal use of drugs of addictionP045 Newborn aff by maternal use of nutritional chemical substncP046 Newborn aff by maternal exposure to environ chemical substncP048 Newborn affected by oth maternal noxious substancesP049 Newborn affected by maternal noxious substance, unspNewborn diagnoses Definitions of Medicare code EditsSeptember 2011P0500 Newborn light for gestational age, unspecified weightP0501 Newborn light for gestational age, less than 500 gramsP0502 Newborn light for gestational age.

9 500-749 gramsP0503 Newborn light for gestational age, 750-999 gramsP0504 Newborn light for gestational age, 1000-1249 gramsP0505 Newborn light for gestational age, 1250-1499 gramsP0506 Newborn light for gestational age, 1500-1749 gramsP0507 Newborn light for gestational age, 1750-1999 gramsP0508 Newborn light for gestational age, 2000-2499 gramsP0510 Newborn small for gestational age, unspecified weightP0511 Newborn small for gestational age, less than 500 gramsP0512 Newborn small for gestational age, 500-749 gramsP0513 Newborn small for gestational age, 750-999 gramsP0514 Newborn small for gestational age, 1000-1249 gramsP0515 Newborn small for gestational age, 1250-1499 gramsP0516 Newborn small for gestational age, 1500-1749 gramsP0517 Newborn small for gestational age, 1750-1999 gramsP0518 Newborn small for gestational age, 2000-2499 gramsP052NB aff by fetal malnut not light or small for gestatnl ageP059 Newborn affected by slow intrauterine growth, unspecifiedP0700 Extremely low birth weight newborn, unspecified weightP0701 Extremely low birth weight newborn, less than 500 gramsP0702 Extremely low birth weight newborn, 500-749 gramsP0703 Extremely low birth weight newborn, 750-999 gramsP0710 Other low birth weight newborn, unspecified weightP0714 Other low birth weight newborn, 1000-1249 gramsP0715 Other low birth weight newborn, 1250-1499 gramsP0716 Other low birth weight newborn, 1500-1749 gramsP0717 Other low birth weight newborn.

10 1750-1999 gramsP0718 Other low birth weight newborn, 2000-2499 gramsP0720 Extreme immaturity of newborn, unspecified weeksP0721 Extreme immaturity of newborn, less than 24 completed weeksP0722 Extreme immaturity of newborn, 24-26 completed weeksP0723 Extreme immaturity of newborn, 27 completed weeksP0730 Other preterm newborn, unspecified weeksP0731 Other preterm newborn, 28-31 completed weeksP0732 Other preterm newborn, 32-36 completed weeksP080 Exceptionally large newborn babyP081 Other heavy for gestational age newbornP0821 Post-term newbornP0822 Prolonged gestation of newbornP09 Abnormal findings on neonatal screeningP100 Subdural hemorrhage due to birth injuryP101 Cerebral hemorrhage due to birth injuryP102 Intraventricular hemorrhage due to birth injuryP103 Subarachnoid hemorrhage due to birth injuryP104 Tentorial tear due to birth injuryP108 Oth intcrn lacerations and hemorrhages due to birth injuryP109 Unsp intcrn laceration and hemorrhage due to birth injuryP110 Cerebral edema due to birth injuryP111 Other specified brain damage due to birth injuryP112 Unspecified brain damage due to birth injury