The Medicare Code Editor (MCE) detects and reports errors in the coding claims data. The following is a list of applicable ICD-10-PCS Code Edits by category.
The procedures codes identified here are always non-covered procedures.
ICD-10-PCS procedure codes for pancreas transplants (0FYG0Z0, 0FYG0Z1) alone [without kidney transplant codes (0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2)] are considered "Non-covered procedures" except for the following condition: When either 0FYG0Z0 (Transplantation of Pancreas, Allogeneic, Open Approach) or 0FYG0Z1 (Transplantation of Pancreas, Syngeneic, Open Approach) is combined with at least one principal or secondary diagnosis code from the following diagnoses list.
The procedures shown below are identified as "Non-covered procedures" when the beneficiary is over age 60.
The procedure codes shown below are identified as non-covered procedures only when ICD-10-CM diagnosis code Z30.2 (Encounter for sterilization) is listed as the principal diagnosis or secondary diagnosis.
For certain procedures whose medical complexity and serious nature incur extraordinary associated costs, Medicare limits coverage to a portion of the cost.
The following procedure code should only be coded on claims when the respiratory ventilation is provided for greater than four consecutive days during the length of stay.
Medicare Code Editor detects inconsistencies between a patient’s sex and any procedures on the patient’s record, the codes in this category apply to FEMALES only.
Medicare Code Editor detects inconsistencies between a patient’s sex and any procedures on the patient’s record, the codes in this category apply to MALES only.