Questionable Admission Codes ICD-10-CM
The questionable admission codes edit is a check in Medicare’s claim-validation software, the Medicare Code Editor (MCE). It covers the 30 ICD-10-CM diagnosis codes listed below. When one of these codes is the principal diagnosis, the MCE flags the admission as questionable, because the condition alone is not normally sufficient justification for acute inpatient care.
Diagnosis Codes in This Edit 30 codes · 11 categories
E11 Type 2 diabetes mellitus2 codes
E13 Other specified diabetes mellitus1 code
- E13.9 Other specified diabetes mellitus without complications
E66 Overweight and obesity6 codes
H61 Other disorders of external ear4 codes
I10 Essential (primary) hypertension1 code
- I10 Essential (primary) hypertension
I44 Atrioventricular and left bundle-branch block5 codes
I45 Other conduction disorders3 codes
R03 Abnormal blood-pressure reading, without diagnosis1 code
- R03.0 Elevated blood-pressure reading, without diagnosis of hypertension
R97 Abnormal tumor markers2 codes
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status1 code
- Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
Z45 Encounter for adjustment and management of implanted device4 codes
- Z45.010 Encounter for checking and testing of cardiac pacemaker pulse generator [battery]
- Z45.018 Encounter for adjustment and management of other part of cardiac pacemaker
- Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator
- Z45.09 Encounter for adjustment and management of other cardiac device
Questions About This Code Edit
What is the questionable admission codes Medicare code edit?
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. The following list contains diagnosis codes identified as questionable admission when used. Claims that fail the check are flagged for correction before payment.
How many ICD-10-CM codes are on the questionable admission codes list?
The FY 2026 list contains 30 diagnosis codes across 11 code categories, imported from the CMS Definitions of Medicare Code Edits v43.0.
What happens when a claim triggers this edit?
When one of these codes is the principal diagnosis, the MCE flags the admission as questionable, because the condition alone is not normally sufficient justification for acute inpatient care.
Does this edit make the codes invalid for billing?
No. Every code on this list is a valid ICD-10-CM code. The edit checks how the code is used on the claim, not whether the code exists.
Other ICD-10-CM Medicare Code Edits
Source: CMS Definitions of Medicare Code Edits v43.0, effective October 1, 2025 through September 30, 2026. Code lists are imported directly from the official manual. See also the ICD-10-PCS procedure edits and the MS-DRG list.
