ICD-10-PCS Code Edits

Non-covered Procedure Codes are ICD-10-PCS codes that represent procedures Medicare does not cover under any circumstances. These procedures are excluded from reimbursement because they are considered not medically necessary, experimental, or outside the scope of covered Medicare benefits. Claims containing these codes will be denied regardless of the patient’s condition or clinical setting. Understanding and identifying non-covered procedure codes is essential for medical billers and coders to prevent claim rejections and ensure accurate claim submission.

Certain ICD-10-PCS procedure codes are classified as non-covered when performed on beneficiaries over the age of 60. These edits are designed to prevent billing for procedures that are not considered medically appropriate or routinely covered for older patients. Claims submitted with these procedures for patients above age 60 will be denied, regardless of medical setting, unless a specific coverage exception applies.

Sterilization procedures are identified by the Medicare Code Editor (MCE) as non-covered under Medicare benefits. These ICD-10-PCS codes represent procedures performed to intentionally and permanently prevent conception, which Medicare does not consider medically necessary for coverage. Claims submitted with sterilization procedure codes will be denied, regardless of patient circumstances, unless they are performed for a medically necessary reason unrelated to voluntary sterilization.

Some ICD-10-PCS procedure codes represent services with significant medical complexity and high associated costs. For these procedures, Medicare provides limited coverage, reimbursing only a portion of the total expense. This edit ensures that claims for costly, high-risk procedures are billed appropriately and that providers and billers are aware of potential out-of-pocket costs for beneficiaries.

This edit applies when a procedure code is reported without the required minimum duration of care. For example, certain respiratory ventilation codes should only be assigned if the patient received mechanical ventilation for more than four consecutive days during the length of stay. If the reported procedure does not meet the required timeframe, the claim will be flagged for inconsistency. This ensures that coding accurately reflects the intensity and duration of the services provided.

The Medicare Code Editor (MCE) identifies certain obstetric diagnosis codes that, on their own, may not provide sufficient justification for admission to an acute care hospital. These edits are designed to flag cases where the reported diagnosis does not clearly indicate the medical necessity for inpatient obstetric care. By reviewing these codes, Medicare helps ensure that hospital admissions for obstetric patients are supported by appropriate clinical documentation and meet medical necessity requirements.

*** Deactivated as of 10/01/2024 ***

The Medicare Code Editor (MCE) reviews inpatient claims to ensure procedures are clinically appropriate for the patient’s documented sex. Codes in this category apply exclusively to female patients and will trigger an edit if reported for a male beneficiary. This safeguard helps prevent errors such as assigning gynecological or obstetric procedures to male patients, ensuring coding accuracy and compliance with Medicare guidelines.

*** Deactivated as of 10/01/2024 ***

he Medicare Code Editor (MCE) checks inpatient claims to confirm that procedures are appropriate for the patient’s documented sex. Codes in this category apply only to male patients and will generate an edit if reported for a female beneficiary. This safeguard prevents errors such as assigning prostate or other male-specific procedures to female patients, supporting accurate coding and Medicare compliance.