Advanced Clinical Editing For Providers
Edit List - 2018
ACE Edit Flag |
ACE Edit Description |
26TC |
The global procedure code <1> has been submitted in history on claim ID <2> without the modifiers |
ANE |
Procedure XXXXX was billed by a provider not listed as an Anesthesiology provider. |
ASD |
An anesthesia service with an equal or higher base unit value than [XXXXX] was billed on |
BAG |
Per LCD or NCD guidelines, procedure code G0102 has not met the associated Age relationship |
BCC |
Per LCD or NCD guidelines, procedure code G0247 has not met the associated Code-to-Code |
BDS |
The beginning or ending Date of Service (DOS) is invalid or missing. |
BFR |
Per LCD or NCD guidelines, procedure code G0445 has not met the associated Frequency |
BPO |
Per LCD or NCD guidelines, procedure code G0445 has not met the associated Place of Service |
BPS |
The place of service XX is missing or invalid. |
BSP |
Per LCD or NCD guidelines, procedure code G0445 has not met the associated Provider Specialty |
BSX |
Per LCD or NCD guidelines, procedure code 77052 has not met the associated Gender relationship |
CAG |
Procedure Code XXXXX is not typical for a patient whose age is XX. The typical age range for this |
CAG1 |
Procedure code 99100 is not typical for age of patient. |
CDL |
Procedure Code <1> has been deleted as of <2>. |
CPO |
Only one individual may report a single care plan oversight CPT code per patient in the same month. |
CPO1 |
Procedure code 99091 cannot be reported within 30 days of the care plan oversight code reported on |
CPT |
Ï Procedure code XXXXX is invalid. |
CSX |
Procedure code <1> is not typically performed for a patient whose gender is <2>. |
DLP |
Procedure code <1> is a possible duplicate of the same procedure code found on Claim ID <2>, Line |
DLPA |
Procedure code <1> is a possible duplicate of the same procedure code found on Claim ID <2> |
DLPB |
Procedure code <1> is a possible duplicate of the same procedure code found on Claim ID <2> |
DLPG |
Procedure code <1> is a possible duplicate of the same procedure code found on Claim ID <2> |
DOB |
Patients Date of Birth is missing or invalid.\ |
DTU |
Discrepancy detected between the number of units XX on this claim line and the difference between |
ESR1 |
It is inappropriate to submit an ESRD related service code (4 or more face-to-face visits based on |
ESR2 |
It is inappropriate to submit an ESRD related service code (2-3 face-to-face visits based on patient's |
ESR3 |
It is inappropriate to submit an ESRD related service code (1 face-to-face visit based on patient's age) |
Page 1 of 8
Advanced Clinical Editing For Providers
Edit List
ACE Edit Flag |
ACE Edit Description |
FCRP |
Procedure code <1> found on claim ID <2> is a facility service code. This service is not to be reported |
GFP |
Procedure Code XXXXX is within the global period of 10 days of History Procedure Code XXXXX |
GFP1 |
Procedure Code <1> is within the global period of a surgical procedure code performed by the same |
GSP |
Procedure Code [XXXXX] is within the global period of XX days of History Procedure Code [YYYYY] |
HBS |
A hysterectomy must be reported by specialty General Surgeon (2), Obstetrics/Gynecology (16), |
HPS |
A hysterectomy following surgical treatment of an ectopic pregnancy or a c/section delivery may not |
IAG |
Dx XXXYY is not typical for a patient whose age is (XX). The typical age range for this diagnosis is X- |
ICD |
Ï The diagnosis XXXYY is invalid |
ICM |
There is no Primary Diagnosis listed for this procedure. |
IDCD |
Diagnosis codes <1> identify mutually exclusive codes; two conditions that cannot be reported |
IDCI |
Diagnosis codes <1> identify mutually exclusive codes; two conditions that cannot be reported |
IDL |
Dx XXXYY has been deleted. |
IDX |
Dx XXXYY is a nonspecific diagnosis code and requires a fourth and/or fifth digit. |
IMC |
Modifier XX cannot be billed on the same claim line as modifier YY. |
IMD |
The diagnosis XXXX and modifier YY combination are inappropriate.. |
IMO |
Modifier XX is invalid or disabled. |
INJ |
Separate reporting is allowed for the supply code of injectable materials provided in POS <1> when |
INJ1 |
Separate reporting is allowed for the injection procedure performed in POS <1> when supply code |
ISX |
Diagnosis code(s) <1> typically would not be reported for a patient whose gender is <2>. |
LBI |
Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Diagnosis Code |
LBM |
Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Modifier Code |
LBP |
Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Primary Diagnosis |
LBS |
Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Secondary |
LBT |
Per LCD or NCD guidelines, procedure code XXXXX, has not met the associated Tertiary Diagnosis |
LNM |
Inappropriate use of a repeat modifier with a laboratory procedure. |
LPR |
Repeat lab procedure XXXXX may require a repeat modifier. |
M26 |
Procedure Code XXXXX requires a modifier -26 when billing for the professional component in place |
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Advanced Clinical Editing For Providers
Edit List
ACE Edit Flag |
ACE Edit Description |
M51 |
Procedure code XXXXX has been billed on the same DOS as another procedure without an |
M62 |
Modifier 62 is not present on procedure code <1> and is reported by a different provider on claim ID |
M62R |
Procedure code requires modifier 62. |
mAM |
Per Medicare guidelines, HCPCS Code " + the adjusted procedure code of 'the current line' + " is |
mAM |
Per CMS guidelines, HCPCS Code <1> is identified as an ambulance code and requires an |
mANM |
Anesthesia code on this line requires an appropriate modifier. |
mAS |
Medicare statutory payment restriction for assistants at surgery applies to the procedure XXXXX. |
mAT |
Per Medicare guidelines procedure code <1> requires modifier GP, GO, or GN. |
mAWF |
Per Medicare, this service is covered once in a lifetime. |
mAWP |
Service occurred within a year of an initial preventive physical exam. |
mAWS |
Service occurred within a year of last covered annual wellness visit. |
mCO |
Billing for co-surgeons is not permitted for the procedure XXXXX. |
mDP |
Procedure Code [XXXXX] is within the global period of ZZ days of History Procedure Code [YYYYY] |
mDT |
Per the Medicare Physician Fee Schedule, Procedure Code XXXXX describes a diagnostic procedure |
mEM |
Ï E/M code [XXXXX] is billed the same date of service as a minor procedure without an appropriate |
mEPG |
Evaluative procedure code <1> requires the reporting of one or more functional G-codes, G8978- |
mEV |
Procedure Code [XXXXX] was performed on the same day of History Procedure Code [YYYYY] |
MF30 |
Procedure code <1> may not be reported more than once in a 30 day period. |
MF90 |
Procedure code <1> may not be reported more than once in a 90 day period. |
MFD |
Procedure Code XXXXX with an allowed daily frequency of XX has been exceeded by YY for date of |
mFL |
Per Medicare guidelines, a diagnosis code(s), which meets medical necessity for procedure code |
mFP |
Procedure Code [XXXXX] is within the global period of XY days of History Procedure Code [YYYYY] |
MFX1 |
The maximum frequency for the procedure code has been exceeded. The allowable maximum |
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Advanced Clinical Editing For Providers
Edit List
ACE Edit Flag |
ACE Edit Description |
mGT |
Per the Medicare Physician Fee Schedule, procedure code XXXXX describes the global code of a |
mHB |
Per Medicare guidelines, the associated administration code for vaccine procedure code [XXXXX], is |
mI10 |
Per CMS guidelines ICD9 codes and ICD10 codes cannot be billed on the same claim. |
mI9 |
Per CMS guidelines ICD-9 codes cannot be billed with dates of service greater than September, 30, |
mIC |
Per Medicare guidelines, procedure code <1> is a service covered incident to a physician's service |
mIM |
Ï Modifier 26 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule. |
mIM |
Modifier is not appropriate for procedure code. |
ML1 |
Modifier L1 is inappropriate to be reported on a professional claim. It is appropriate to report on a |
mLP |
Per the Medicare Physician Fee Schedule, Procedure XXXXX is inappropriate with Modifier -TC. |
mM51 |
Procedure code XXXXX has been billed on the same DOS as another procedure without an |
mMEY |
Per Medicare guidelines, all claim lines on the same claim must contain the modifier EY. |
mMFL |
Per CMS guidelines, the associated administration or drug code for vaccine code <1> is missing or |
mMFQ |
A severity/complexity modifier, CH, CI, CJ, CK, CL, CM, CN is required to be appended to Medicare |
mMGK |
Modifier GK cannot be submitted alone, another line with GA or GZ must be present on the same |
mMHB |
Per Medicare guidelines, the associated administration code for vaccine procedure code [XXXXX], is |
mMPN |
Per Medicare guidelines, the associated administration code for vaccine procedure code [XXXXX], is |
mMSP |
Per Medicare guidelines the diagnosis code(s) billed does not support the medical necessity of |
mMUE |
Per Medicare's Medically Unlikely Edits, the units of service billed for procedure code XXXXX exceed |
mMUE |
Per Medicare's Medically Unlikely Edits, the units of service billed for procedure code <1> exceed the |
mNG |
A procedure code with a Medicare global follow up period could not be located in the last six months |
Page 4 of 8
Advanced Clinical Editing For Providers
Edit List
ACE Edit Flag |
ACE Edit Description |
mNP |
Procedure Code XXXXX does not typically require performance by a physician in Place of Service XX |
MOD |
Use of modifier XX (crosswalks to YY), is not typical for procedure XXXXX. |
MOD57 |
An E/M code <1> reported with modifier 57 was provided on the same date as a minor surgical |
mOG |
Proc [99024] is outside the Medicare global period of ZZ days for Hx Proc [XXXXX] performed on |
mPC |
Per the Medicare Physician Fee Schedule, procedure code XXXXX describes the physician work |
mPDP |
The PD modifier must be billed with the 26 modifier. |
mPDT |
The PD modifier may not be billed with the TC modifier. |
mPI |
Per the Medicare Physician Fee Schedule, procedure code XXXXX describes a physician |
mPN |
Per Medicare guidelines, a diagnosis code(s), which meets medical necessity for procedure code |
mPS |
Per the Medicare Physician Fee Schedule, procedure code XXXXX describes the physician services. |
mPT |
Procedure Code XXXXX is a physical therapy service. No payment is made if provided in Place of |
mPT |
Per Medicare guidelines, procedure code <1> is a physical therapy service. No payment is made if |
mSB |
Add-on procedure code XXXXX has been submitted without an appropriate primary procedure. |
mSP |
Per Medicare guidelines procedure code XXXXX is within the global period of history procedure code |
mTC |
Per the Medicare Physician Fee Schedule, procedure code XXXXX describes only the technical |
mTH |
Per Medicare guidelines procedure code <1> requires modifier GT or GQ. |
mTS |
Team Surgery is not permitted for Procedure XXXXX. |
mUM |
Per Medicare Guidelines, Procedure Code XXXXX has an unbundle relationship with Procedure Code |
mUN |
Per CCI Guidelines, Procedure Code XXXXX has an unbundle relationship with history Procedure |
mUO |
Per CCI Guidelines, Procedure Code XXXXX [PROCEDURE DESCPRITION] has an unbundle |
N51 |
Procedure code XXXXX has been billed with the modifier 51, either the procedure code has the |
NGP |
A procedure code with a Global Follow-up period could not be located in the patient's history. Report a |
NPT |
This patient received care by provider <1> on Claim ID <2> on Date of Service <3> and is within three |
NPTh |
A new patient E/M was reported on Claim ID <1> within the last three years. An established patient |
Page 5 of 8
Advanced Clinical Editing For Providers
Edit List
ACE Edit Flag |
ACE Edit Description |
OBA |
Antepartum care code <1> cannot be submitted 280 days prior to global delivery codes 59400, 59510, |
OGP |
A procedure code with a Global Follow-up period could not be located in the patient's history. Report a |
ONL |
Online code <1> cannot be reported for services related to an E/M provided in the previous 7 days. |
PAT |
The patient ID is missing. |
PCM |
Modifier -26 is not appropriate with Procedure Code XXXXX because that procedure is defined as |
PDO |
The ICD-10-CM code <1> may only be used as first-listed or primary diagnosis position. |
POS |
Procedure Code XXXXX is not typically performed by a physician at Place of Service XX [description |
PPGD |
It is not appropriate to submit postpartum code 59430 within 49 days of an obstetrical package code |
PRE |
Pre-Op E/M Service [XXXXX] performed one day before the History Surgical Procedure Code |
PRS |
Ï The Provider Specialty is missing. |
PRV |
The Provider ID and/or Department ID are missing. |
PSX |
The Gender for this patient is either missing or invalid. |
RDL |
Repeat radiology procedure XXXXX may require a repeat procedure modifier. |
RNM |
Inappropriate use of a repeat modifier with a radiology procedure. |
S51 |
Procedure code XXXXX is an add-on code. Modifier 51 (Multiple Procedures) is not appropriate with |
sAG |
Per Medicaid guidelines, the patient's age does not meet policy requirements for the procedure code |
SAM |
There is more than one occurrence of Proc [XXXXX], on the same date of service, on Claim ID - |
sAM |
Per Medicaid guidelines, HCPCS Code <1> is identified as an ambulance code and requires an |
sANM |
Per Medicaid guidelines, anesthesia code <1> on claim line ID <2> requires an appropriate modifier. |
SAS |
Procedure Code XXXXX typically requires no surgical assistant. |
sCC |
Per Medicaid guidelines, an additional procedure code is needed to meet policy requirements. |
sDP |
Per Medicaid guidelines, this procedure code is within the global period of a procedure code found in |
sDSP |
Per Medicaid guidelines, a primary diagnosis code, which meets medical necessity for the procedure |
sDSS |
Per Medicaid guidelines, a secondary diagnosis code, which meets medical necessity for the |
sDT |
Per Medicaid guidelines, procedure code <1> describes a diagnostic procedure that requires a |
sEM |
Per Medicaid guidelines, E/M code <1> billed on the same day of a minor procedure or the same day |
Page 6 of 8
Advanced Clinical Editing For Providers
Edit List
ACE Edit Flag |
ACE Edit Description |
sEV |
Per Medicaid guidelines, procedure code <1> was performed on the same day of procedure code <2> |
sFP |
Per Medicaid guidelines, E/M code <1> is within the global period of procedure code <2> found in |
sFR |
Per Medicaid guidelines, the frequency does not meet policy requirements for the procedure code. |
sGT |
Per Medicaid guidelines, modifier <1> is inappropriately appended to procedure code <2>. |
sIM |
Per Medicaid guidelines, modifier <1> is not appropriate for procedure code <2>. |
sLP |
Per Medicaid guidelines, procedure code <1> is inappropriate with Modifier TC. Performance of the |
sMEY |
Per Medicaid guidelines, all claim lines on the same claim must contain the modifier EY. |
sMGK |
Per Medicaid guidelines, modifier GK cannot be submitted alone, another line with GA or GZ must be |
sMN |
Per Medicaid guidelines, a diagnosis code which meets medical necessity is missing or invalid. |
sMPP |
Per Medicaid guidelines, procedure code <1> cannot be billed without first billing procedure code <2>. |
sMVC |
Per Medicaid guidelines, the associated vaccine code for administration procedure code <1> is |
sNBT |
Per Medicaid guidelines, procedure code <1> and procedure code <2> on claim ID <3> cannot be |
sNP |
Per Medicaid guidelines, procedure code <1> does not typically require performance by a physician in |
sOG |
Per Medicaid guidelines, procedure code 99024 is outside the global period of a related procedure |
sPC |
Per Medicaid guidelines, procedure code <1> describes the physician work portion of a diagnostic |
sPEC |
Per Medicaid guidelines, claim ID <1> is missing or has an invalid provider specialty ID. |
sPI |
Per Medicaid guidelines, procedure code <1> describes a physician interpretation for a service and is |
sPOS |
Per Medicaid guidelines, the place of service code is missing or invalid for procedure code <1>. |
sPS |
Per Medicaid guidelines, procedure code <1> describes the physician service. Use of modifier 26 or |
sRM |
Per Medicaid guidelines, the required modifier is missing or the modifier is inappropriate for the |
sSB |
Per Medicaid guidelines, add-on procedure code <1> has been submitted without an appropriate |
sSP |
Per Medicaid guidelines, procedure code <1> is within the global period of procedure code <2> found |
sSX |
Per Medicaid guidelines, the patient's gender does not meet policy requirements for the procedure |
sTC |
Per Medicaid guidelines, procedure code <1> describes only the technical portion of a service or |
Page 7 of 8
Advanced Clinical Editing For Providers
Edit List
ACE Edit Flag |
ACE Edit Description |
SUBD |
A definitive add-on procedure code <1> has been submitted without an appropriate primary procedure |
SUBI |
An interpreted add-on code <1> has been submitted without an appropriate primary procedure code. |
sUM |
Per Medicaid guidelines, the current procedure code has an unbundled relationship with a procedure |
sUN |
Per Medicaid National Correct Coding Initiative edits, Procedure Code [XXXXX] has an unbundle |
sUO |
Per Medicaid National Correct Coding Initiative edits, Procedure Code [XXXXX] [description of |
sVP |
Per Medicaid guidelines, this procedure code has been billed without a corresponding venipuncture |
TCM |
<1> is included in transitional care management service, 99495-99496, when reported in the same 30 |
TCMh |
A procedure code found in history on Claim ID <1> is included in transitional care management |
TEL |
Telephone code <1> cannot be reported for services related to an E/M provided in the previous 7 |
UEX |
Procedure Code XXXXX [PROCEDURE DESCRIPTION] has an Exclusive relationship with |
UNB25 |
Modifier 25 should only be reported on an E/M code <1> when another claim with the same provider |
UNB57 |
Modifier 57 may only be reported on E/M code <1> when another claim is found in history, for the |
UNID |
Report only remote services when an in person interrogation device evaluation is performed during the |
UNSL |
The ICD-10-CM code(s) reported define an unspecified ICD-10-CM diagnosis code which has an |
UOV |
Procedure Code XXXXX [PROCEDURE DESCRIPTION] has an Unbundle relationship with |
VEN |
Procedure code <1> has been reported on <2> without a corresponding venipuncture code. Add a |
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