ICD-10-CM Medicare Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding claims data. The editor checks each diagnosis including the admitting diagnosis and each procedure against a table of valid ICD codes. If an entered code does not agree with any code on the internal list, it is assumed to be invalid. The editor also 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 delivery.

The Medicare Code Editor detects inconsistencies between a patient's sex and any diagnosis or procedure on the patient's record. For example, a male patient with cervical cancer (diagnosis) or a female patient with a prostatectomy (procedure). In both instances, the indicated diagnosis or the procedure conflicts with the stated sex of the patient. Therefore, either the patient's diagnosis, procedure or sex is presumed to be incorrect.

The Medicare Code Editor detects inconsistencies between a patient's sex and any diagnosis or procedure on the patient's record. For example, a male patient with cervical cancer (diagnosis) or a female patient with a prostatectomy (procedure). In both instances, the indicated diagnosis or the procedure conflicts with the stated sex of the patient. Therefore, either the patient's diagnosis, procedure or sex is presumed to be incorrect.

The following is a list of applicable ICD-10-CM Code Edits by category.

Adult diagnoses

Adult code edits validate age range is 15–124 years inclusive (e.g., senile delirium, mature cataract).

Diagnoses for females only

Medicare Code Editor detects inconsistencies between a patient's sex and any diagnosis on the patient's record, the codes in this category apply to FEMALES only.

Diagnoses for males only

Medicare Code Editor detects inconsistencies between a patient's sex and any diagnosis on the patient's record, the codes in this category apply to MALES only.

Maternity diagnoses

Maternity. Age range is 12–55 years inclusive (e.g., diabetes in pregnancy, antepartum pulmonary complication).

Newborn diagnoses

Newborn. Age of 0 years; a subset of diagnoses intended only for newborns and neonates (e.g., fetal distress, perinatal jaundice).

Pediatric diagnoses

Pediatric. Age range is 0–17 years inclusive (e.g., Reye's syndrome, routine child health exam).

Questionable admission codes

Some diagnoses are not usually sufficient justification for admission to an acute care hospital. For example, if a patient is given code R030 for elevated blood pressure reading, without diagnosis of hypertension, then the patient would have a questionable admission, since elevated blood pressure reading is not normally sufficient justification for admission to a hospital.

Unacceptable principal diagnosis

There are selected codes that describe a circumstance which influences an individual's health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.