ICD-10-PCS Medicare 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.

Pancreas transplant procedures reported alone, without an accompanying kidney transplant code, are non-covered unless a qualifying type 1 diabetes diagnosis is present on the claim as the principal or a secondary diagnosis. This edit lists the transplant procedure codes and the qualifying diagnosis list.

Certain stem-cell and bone-marrow transfusion procedures are identified as non-covered only when specific leukemia diagnoses are present on the claim as the principal or a secondary diagnosis. This edit lists both the procedure codes and the trigger diagnoses.

Certain ICD-10-PCS procedure codes are classified as non-covered when performed on beneficiaries over the age of 60. Claims submitted with these procedures for patients above age 60 will be denied unless a specific coverage exception applies.

Sterilization procedures are identified by the Medicare Code Editor as non-covered when they are billed with ICD-10-CM diagnosis code Z30.2 (encounter for sterilization) as the principal or a secondary diagnosis. Performed for a medically necessary reason unrelated to voluntary sterilization, the same procedures are paid normally.

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.

Certain external cause codes indicate that the wrong procedure was performed: surgery on the wrong patient, the wrong body part, or a different procedure than the one planned. Medicare does not pay for the associated care, and the Medicare Code Editor flags any claim that carries one of these codes.

This edit applies when a procedure code is reported without the required minimum duration of care. The continuous respiratory ventilation code for greater than 96 hours should only be assigned when the patient received mechanical ventilation for more than four consecutive days during the stay.

Cesarean section and vaginal delivery procedure codes are considered a questionable admission except when reported with a corresponding secondary diagnosis code describing the outcome of delivery. This edit lists the delivery procedures and the outcome of delivery exception diagnoses.

Deactivated by CMS as of October 1, 2024. This edit reviewed inpatient claims to ensure procedures were clinically appropriate for the patient's documented sex, flagging female-only procedures reported for male beneficiaries. The checks are no longer enforced during claims processing.

Deactivated by CMS as of October 1, 2024. This edit reviewed inpatient claims to ensure procedures were clinically appropriate for the patient's documented sex, flagging male-only procedures reported for female beneficiaries. The checks are no longer enforced during claims processing.