| Clinical edit code | Description | Logic |
|---|
| BAG |
LCD Part B procedure not typical with patient age |
Service can only be performed for a specific age range. Applies to Priority Health Medicare professional claims. |
| BCC |
LCD Part B code-to-code missing or invalid |
Claim line does not meet LCD policies. Applies to Priority Health Medicare professional claims. |
| BFR |
LCD Part B procedure frequency exceeded |
Service billed exceeds frequency requirements. Applies to Priority Health Medicare professional claims. |
| BPO |
LCD Part B invalid place of service |
Service can only be performed in a specific place of service. Applies to Priority Health Medicare professional claims. |
| BPS |
Missing or invalid place of service |
Invalid or missing place of service. Applies to Priority Health Medicare professional claims. |
| BRR |
Anesthesia crosswalk - by report |
More appropriate anesthesia code needed for surgical procedure |
| BSP |
LCD Part B missing or invalid provider specialty |
Provider speciality doesn't meet LCD policies. Applies to Priority Health Medicare professional claims. |
| BSX |
LCD Part B missing or invalid patient gender |
Service can only be performed on a specific gender |
| CAG |
Procedure not typical with patient age |
Patient's age is not typical for service |
| CDL |
Deleted procedure code |
Deleted CPT or HCPCS code |
| CPT |
Invalid procedure code |
Not a valid procedure code on date of service |
| CSX |
Procedure not typical with patient gender |
Patient's gender is not typical for service |
| DAP |
Deny add-on procedure |
Add-on procedure with denied primary procedure |
| DOB |
Missing or invalid date of birth |
Missing date of birth or date of service before date of birth |
| DTU |
Date of service to units discrepancy |
Invalid number of units compared to date span. Verify that your dates of service are appropriate for the services billed. |
| GFP |
Global follow-up by provider |
E&M within global follow-up period of a surgical procedure |
| GRP |
Rebundle - retained procedure code from transfer |
Claim line retained as part of group transfer |
| GSP |
Post-op surgery by provider |
Surgical procedure within global follow-up period of a surgical procedure. Example: Member has surgical service and then returns to the operating room within one week for additional surgical services. Additional surgical claims should be reported with the appropriate post-operative modifiers (i.e., 58 for staged, or 78 for return to the operating room). |
| HEX |
History unbundle procedure - exclusive |
Service is a component of a more comprehensive service |
| HIN |
History unbundle procedure - incidental |
Service is a component of a more comprehensive service |
| HNB |
History unbundle procedure - unbundle or incidental |
Service is a component of a more comprehensive service |
| HRB |
History rebundle |
Service is a component of a transfer relationship and rebundled to a more comprehensive code |
| HRP |
History procedure code retained from transfer |
Claim line retained as part of group transfer |
| IAG |
Diagnosis not typical with patient age |
Diagnosis code not appropriate for patient's age |
| IAP |
Not a frequent diagnosis code with procedure |
Diagnosis code not typical for service |
| ICD |
Invalid diagnosis code |
Diagnosis code not valid on date of service |
| ICM |
Missing diagnosis code |
Claim line missing a primary diagnosis code |
| ICR |
Anesthesia crosswalk - individual review |
More appropriate anesthesia code needed for surgical procedure |
| IDX |
Nonspecific diagnosis code |
Diagnosis code requires 4th or 5th digit |
| IMC |
Inappropriate modifier combination |
Innappropriate modifier for claim line. Examples: Reporting 24, 25 on the same claim line. |
| IMO |
Invalid modifier |
Invalid modifier for claim line |
| ISX |
Diagnosis not typical with patient gender |
Diagnosis code not typical for patient's gender |
| LBI |
LCD Part B missing or invalid diagnosis |
Diagnosis doesn't meet non-sequenced diagnosis. Applies to Priority Health Medicare professional claims. |
| LBM |
LCD Part B missing required modifier |
Claim line requires modifier use. Applies to Priority Health Medicare professional claims. |
| LBP |
LCD Part B missing required primary diagnosis |
Primary diagnosis is not covered. Applies to Priority Health Medicare professional claims. |
| LBS |
LCD Part B missing required secondary diagnosis |
Secondary diagnosis does not meet secondary sequencing requirements. Applies to Priority Health Medicare professional claims. |
| LBT |
LCD Part B missing required tertiary diagnosis |
Tertiary diagnosis does not meet tertiary sequencing requirements. Applies to Priority Health Medicare professional claims. |
| LCD |
LCD Part B missing or invalid policy requirement |
Claim line doesn't meet LCD policies. Applies to Priority Health Medicare professional claims. |
| LDY |
LCD Part B deny |
Claim line meets LCD requirements, but services are not payable. Applies to Priority Health Medicare professional claims. |
| LRD |
LCD Part B review/request documents |
Review documentation requested for LCD requirement. Applies to Priority Health Medicare professional claims. |
| M26 |
Modifier 26 required |
Claim line should be billed with modifier 26. Applies to Priority Health Medicare professional claims. |
| mANM |
Medicare anesthesia modifiers |
Billed without appropriate anesthesia modifier. Applies to Priority Health Medicare professional claims. |
| mAP |
Medicare deny add-on procedure |
Add-on procedure with denied primary procedure |
| mAS |
No payment for assistant surgeons |
Assistant at surgery not covered for the billed service. See Billing modifiers 80, 81, 82 in this manual. |
| mBC |
Bundled code |
Add-on procedure code billed without primary procedure. Applies to Priority Health Medicare professional claims. |
| mBI |
Bundled item or service |
Service is incidental to or bundled within another billed professional service. |
| mCO |
Co-surgeons not permitted |
Co-surgeon not payable for billed procedure |
| mD1 |
Document assistant surgeon |
Documentation is required to support the use of assistant surgeon. See Billing modifiers 80, 81, 82 in this manual. |
| mD2 |
Document co-surgeons |
Documentation is required to support the use of co-surgeons. See Billing with modifier 62 in this manual. |
| mD3 |
Document team surgery |
Documentation is required to support the use of surgical team |
| mDT |
Medicare diagnostic testing in a hospital setting |
Code should only be used in facility or skilled nursing setting. Applies to Priority Health Medicare professional claims. |
| mEH |
E&M and surgery without modifier (history edit) |
E&M performed without appropriate modifier on the same day or one day prior to surgical procedure |
| MFD |
Typical daily frequency exceeded |
Claim lines exceed normal daily frequency for procedure code |
| mFP |
Global follow-up by provider |
E&M within follow-up global period for a surgical procedure |
| mSP |
Medicare post-op surgery by provider |
E&M within follow-up global period for a surgical procedure |
| MFX |
Maxiimum frequency exceeded |
Claim lines exceed the normal maximum for procedure code |
| mGT |
Global test only |
26 or TC modifier used inappropriately. Applies to Priority Health Medicare professional claims. |
| mIC |
Modifier |
Modifier 26 or TC not appropriate with CPT or HCPCS. Applies to Priority Health Medicare professional claims. |
| mIM |
Inappropriate modifier |
Inappropriate modifier for service |
| mIN |
Medicare injection service |
Injection service not covered under Medicare. Applies to Priority Health Medicare professional claims. |
| mM54 |
Intraoperative care only reduction |
Appropriate as surgical service only with modifier 54. Claim will process at reduced fee schedule since only component of surgical services performed. |
| mM55 |
Postoperative care only reduction |
Appropriate as surgical service only with modifier 55. Claim will process at reduced fee schedule since only component of surgical services performed. |
| mM56 |
Preoperative care only reduction |
Appropriate as surgical service only with modifier 56. Claim will process at reduced fee schedule since only component of surgical services performed. |
| mMOD |
Medicare modifier |
Inappropriate use of modifier for Medicare. Applies to Priority Health Medicare professional claims. |
| mNP |
Medicare non-physician service |
Procedure is typically not performed by a physician. Applies to Priority Health Medicare professional claims. |
| mNS |
Medicare non-covered service |
Service is not covered by Medicare. Applies to Priority Health Medicare professional claims. |
| mNV |
Medicare not valid for payment |
Procedure code is not valid under Medicare rules. Applies to Priority Health Medicare professional claims. |
| MOD |
Modifier not appropriate with procedure |
Inappropriate modifier for service |
| mPC |
Professional component only |
Modifier 26 or TC not appropriate under Medicare rules. |
| mPI |
Physician interpretation |
TC modifier billed inapprpriately or with a place of service other than inpatient. Applies to Priority Health Medicare professional claims. |
| mPT |
Medicare physical therapy service |
Place of service not allowed for this service under Medicare rules. Applies to Priority Health Medicare professional claims. |
| mSB |
Medicare add-on procedure with out primary procedure |
Add on procedure reported without primary procedure |
| mUN |
Unbundle |
Service is a component of a more comprehensive service |
| mUH |
Medicare unbundle (history edit) |
Service is a component of a more comprehensive service |
| mTC |
Medicare technical component only |
Modifier 26 or TC not appropriate. Applies to Priority Health Medicare professional claims. |
| mTS |
Team surgeons not permitted |
Team surgery not payable for billed procedure |
| NPD |
Not a primary diagnosis code |
Diagnosis code inappropriate as a primary diagnosis |
| NPT |
New patient code billed for established patient - claim history or NPT table |
Claims history identifies the patient as established |
| PAT |
Missing patient ID |
Missing or inappropriate patient ID |
| PCM |
Invalid professional component modifier |
Claim line billed inappropriately with modifier 26. Claim will be processed without applying this modifier; provider does not need to resubmit the claim. |
| PHAS |
Assistant surgeon rule |
Surgery and assistant surgery billed under same physician |
| PHCE |
Capsule endoscopy medical policy |
Non-covered service identified in the Capsule Endoscopy medical policy, 91476 (122KB PDF) |
| PHFC |
Foot care medical policy |
Non-covered service identified in the Foot Care medical policy, 91121 (76KB PDF) |
| PHHO |
Hyperbaric oxygen medical policy |
Non-covered service identified in Hyperbaric Oxygen medical policy, 91151 (170KB PDF) |
| PHSC |
Skin conditions medical policy |
Non-covered service identified in Skin Conditions medical policy, 91456 (110KB PDF) |
| PHVC |
Vision care medical policy |
Non-covered service identified in Vision Care medical policy, 91538 (88KB PDF) |
| POS |
Place of service not typical with procedure |
Place of service is not typical for this service |
| PRE |
Pre-op procedure one day before surgery |
E&M performed on the same day or day prior to surgical procedure |
| PRH |
Pre-op procedure one day before surgery - history edit |
E&M performed on the same day or day prior to surgical procedure |
| REB |
Rebundle |
Service is a component of a transfer relationship and rebundled to a more comprehensive code |
| SAM |
Multiple assistant surgeons not typical |
Claim line already billed with an assistant surgeon; only one assistant surgeon allowed for service. Refer to modifiers 80, 81, 82 in this manual. |
| SAS |
Typically no surgical assistant |
Assistant surgery not covered for the billed service. Refer to modifiers 80, 81, 82 in this manual. |
| TPL |
Third-party liability diagnosis |
Diagnosis flagged as third-party liability |
| TRA |
Rebundle - transfer |
More comprehensive code or code combination is available |
| SUB |
Add-on procedure without primary procedure |
Add-on procedure reported without primary procedure |
| UEX |
Unbundle procedure - exclusive |
Service is a component of a more comprehensive service |
| UIN |
Unbundle procedure - incidental |
Service is a component of a more comprehensive service |
| UNB |
Unbundle procedure - unbundle or incidental |
Service is a component of a more comprehensive service |
| UNL |
Unlisted procedure code |
Requires manual review of medical notes or claims data |
