1. technology and computing
2. software

Preliminary
07/17/09
For personal computers
Medicare Severity Grouper with
Medicare Code Editor Software
Installation and User’s Manual
PB2009-101189
Software version 27.0
PBL–013 October 2009
07/17/09
Preliminary
Microsoft, Windows, and Windows NT are registered trademarks of
Microsoft Corporation in the United States and/or other countries.
Document number
October 2009
ii MS Grouper with Medicare Code Editor Software
PBL–013
October 2009
Preliminary
07/17/09
About this document
Purpose of the manual
This manual is written to assist health information management professionals with an average level of computer knowledge in installing
and using the Medicare Severity Grouper with
Medicare Code Editor (MSG/MCE) software in a Windows® environment on a personal computer.
The documentation assumes you are familiar with Diagnosis Related
Groups (DRGs) methodology for processing medical claims, and
with MCE software’s evaluation of patient data to help identify possible errors in coding.
Information in the manual
The manual begins with a brief introduction describing the functionality of MSG/MCE software. You are then given instructions to
install the software, followed by chapters on processing claims data
interactively and in batch. An appendix is included that lists the
Major Diagnostic Categories (MDCs) and DRGs in the current MS
grouper with the DRG-associated cost weights.
For a general outline of the topics covered in the manual, see the
table of contents immediately following this preface. We
recommend that you also use the index at the back of the
manual to locate specific information.
Sequential steps in the manual to select an option use the “greater
than” symbol. For example, rather than telling you to first go to the
Start menu, select Programs, select Accessories, and finally select
Notepad, that instruction would appear as:
October 2009
iii
07/17/09
❑
Preliminary
From the Start menu, select Programs > Accessories > Notepad.
iv MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Contents
Preface
Chapter 1
About this document iii
Introduction
1.3
Program versions
Chapter 2
1.4
Installing the software
2.3
Hardware and system requirements
Pre-installation note 2.3
Installing the current software product
Description files 2.5
Installed program functions 2.6
Accessing the functions 2.6
Chapter 3
Uninstalling grouper versions
2.7
Interactive data processing
3.3
Data entry
2.3
2.4
3.4
Grouper selection 3.4
Steps for entering data 3.4
Data entry fields 3.7
Data entry menu options 3.11
Data entry command buttons 3.11
Interactive error messages 3.12
Program output
3.13
Viewing interactive output 3.15
Exiting the report window 3.15
Output report fields 3.16
Output report menu options 3.20
Output report command button 3.21
October 2009
Contents v
07/17/09
Program edits
Chapter 4
3.22
Batch processing
4.3
Steps in batch processing
Input file format
Preliminary
4.4
4.6
Command line processing options 4.10
Command line examples 4.11
Output file formats
4.12
Formatted output (-o option) 4.12
Upload file (-u option) 4.12
Working with batch output
Viewing output 4.18
Printing output 4.18
Renaming a file 4.18
4.18
Batch processing error messages
Log files
4.19
4.21
Viewing the file 4.22
Printing the file 4.22
Renaming the file 4.22
Appendix A
Index
Current MDCs and DRGs A.3
I.1
vi MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Figures
Figure
3–1
3–2
4–1
4–2
October 2009
Title and page
Data entry window 3.5
Sample output report 3.14
Batch processing overview 4.4
Sample log file 4.21
Figures vii
07/17/09
viii MS Grouper with Medicare Code Editor Software
Preliminary
October 2009
Preliminary
07/17/09
Tables
Table
1–1
2–1
2–2
2–3
3–1
3–2
3–3
3–4
3–5
3–6
3–7
3–8
3–9
4–1
4–2
4–3
4–4
4–5
4–6
A–1
A–2
October 2009
Title and page
Grouper versions in the program 1.4
Hardware requirements 2.3
Description files 2.5
Installed program functions 2.6
Help for interactive data entry 3.6
Data entry fields 3.7
Data entry menu items 3.11
Data entry command buttons 3.11
Interactive error messages 3.12
Interactive output report fields 3.16
Output report menu items 3.20
Output report command button 3.21
Program edits 3.22
Batch processing performance information 4.5
Input file record layout 4.6
Batch processing options 4.10
Batch processing output 4.12
Upload file record layout 4.13
Batch processing error messages 4.19
List of MDCs A.3
List of DRGs with cost weights A.4
Tables
ix
07/17/09
x MS Grouper with Medicare Code Editor Software
Preliminary
October 2009
Preliminary
07/17/09
Chapter 1
Introduction
1
07/17/09
Contents
Introduction
1.3
Program versions
1.2 MS Grouper with Medicare Code Editor Software
Preliminary
1.4
October 2009
Preliminary
07/17/09
Chapter 1
Introduction
T
HE MEDICARE SEVERITY GROUPER with Medicare Code
Editor (MSG/MCE) software edits medical record data to help identify coding errors and inconsistencies between clinical data and
coding.
➤
Note: Starting with version 25, the grouper name was changed from
the Centers for Medicare and Medicaid Services (CMS) DRGs to
Medicare Severity DRGs (MS-DRGs), also referred to as MS
grouper.
The software:
October 2009
◆
Assigns the medical record to a Major Diagnostic Category
(MDC) and a Diagnosis Related Group (DRG).
◆
Displays clinical edits that identify inconsistencies after evaluating a patient’s principal diagnosis, any secondary diagnoses,
surgical procedures, age, sex, and discharge status for possible
errors.
◆
Displays the cost weight associated with the assigned DRG for
each patient record.
◆
Automatically calls the appropriate MS grouper to process the
claim based on the groupers installed and the discharge date
entered on the patient record. For example, if the discharge date
on the record were November 14, 2008, MS grouper 26 with an
effective date range of 10/01/2008–09/31/2008 would be used to
process the claim. If the
discharge date is 10/01/2009 or later, MS grouper 27.0 is used.
◆
Processes medical record data either from a MS-DOS batch file
or interactively in a Windows environment.
Introduction 1.3
07/17/09
Program versions
Preliminary
This release of MS grouper with MCE software for Windows-based
personal computers supports versions 17.0–27.0 of the grouper, as
shown in table 1–1. To process a claim using an CMS grouper prior
to version 17.0, you must use the earlier version of CMS Grouper
with MCE software that runs under DOS.
Table 1–1.
Grouper versions in the program
MS grouper version
MCE version
Effective date range
27.0
26.0
10/01/2009–09/30/2010
26.0
25.0
10/01/2008–09/30/2009
25.1
24.1
04/01/2008–09/30/2008
25.0
24.0
10/01/2007–03/31/2008
24.0
23.0
10/01/2006–09/30/2007
23.0
22.0
10/01/2005–09/30/2006
22.0
21.0
10/01/2004–09/30/2005
21.0
20.0
10/01/2003–09/30/2004
20.0
19.0
10/01/2002–09/30/2003
19.0
18.0
10/01/2001–09/30/2002
18.0
17.0
10/01/2000–09/30/2001
17.0
16.0
10/01/1999–09/30/2000
16.0
15.1
07/01/1999–09/30/1999
16.0
15.0
10/01/1998–06/30/1999
Version 27.0 of the MS grouper supports ICD-9-CM diagnosis and
procedures codes with their descriptions, effective
October 1, 2009.
There are specific rules for the discharge date field as it relates to the
discharge status and the version of software used to process a claim.
See table 3–2 on page 3.7 for details.
1.4 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Chapter 2
Installing the software
2
07/17/09
Contents
Preliminary
Installing the software 2.3
Hardware and system requirements
Pre-installation note 2.3
Installing the current software product
Description files 2.5
Installed program functions 2.6
Accessing the functions 2.6
Uninstalling grouper versions
2.2 MS Grouper with Medicare Code Editor Software
2.3
2.4
2.7
October 2009
Preliminary
07/17/09
Chapter 2
Installing the software
THE MEDICARE SEVERITY GROUPER WITH MEDICARE
CODE EDITOR (MSG/MCE) software is completely self-installable
on a stand-alone personal computer (PC). The installation must be
performed by a person with Windows administrative status. The software is not designed for networked systems.
Hardware and system
requirements
The hardware and system requirements for the software are shown in
table 2–1.
Table 2–1. Hardware requirements
Pre-installation note
October 2009
Operating system
Windows 2000 (service pack 3)
Windows 2003
Windows XP (service pack 1)
Windows Vista
RAM
64Mb
Available disk space
120Mb
Monitor
Super VGA color (1024x768) resolution)
Windows permissions
Administrative status
If you already have MSG/MCE (formerly CMSG/MCE) Windows
software version 25.1 or older installed on your system, you must
uninstall it before installing the current software. For instructions on
how to uninstall a previous version of the software, refer to
“Uninstalling grouper versions” on page 2.7.
Installing the software 2.3
07/17/09
Preliminary
Installing the current software product
To install the current version of MS grouper with MCE software, follow the steps below. The installation automatically checks for the
appropriate operating system, screen resolution, free disk space,
administrator status, and previously installed MSG/MCE software
versions. If any requirement is not met, you will see a message stating the nature of the problem during the installation. Correct the
problem and begin the installation again. At any time, you can click
Cancel to end the installation process.
❑
With your computer turned on, close all unnecessary applications running on your computer.
❑
Insert the product CD into the CD-ROM drive.
The installation procedure will start automatically unless your
auto-run feature is turned off.
If the setup does not start in a few seconds, browse to your CD drive
and select the following executable:
Disk1\InstData\VM\MSGMCEInstaller.exe
You see a message stating that InstallAnywhere® is preparing to
install.
❑
On the Introduction screen, read the introductory information,
then click Next to continue.
If a previous version of the software is detected on your system, you
see a message instructing you to uninstall the previous version before
proceeding with the new installation.
❑
On the Choose Install Folder screen, specify the folder where
you want to install the product.
The default folder is C:\Program Files\MSG MCE SOFTWARE.
◆
To choose a different folder, click Choose and browse to the
folder you want to use.
◆
If you want to restore the default folder after making a change,
click Restore Default Folder
❑
After choosing an install folder, click Next.
❑
Review the information on the Pre-Installation Summary screen.
2.4 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
If you need to make any changes, click Previous and make the necessary changes, then click Next to return to the Pre-Installation
Summary screen.
❑
When you are satisfied with the pre-installation summary
information, click Install.
While the installation process runs, you see the Installing screen. If
errors occur, you see a message directing you to the installation log
for more information.
❑
Description files
On the Install Complete screen, click Done.
Files containing descriptions for diagnosis and procedure codes,
DRGs, and MDCs are included as part of the installation process.
The files, listed in table 2–2, are located in the Descriptions directory
off the product directory. In the file names, xxx represents to current
software version number.
Table 2–2.
➤
October 2009
Description files
File name
Contains descriptions for...
icd9dx.vxxx
ICD-9-CM diagnosis codes
icd9sg.vxxx
ICD-9-CM procedure codes
msdrg3.vxxx
3-digit DRGs
msdrg4.vxxx
4-digit DRGs
msmdc.vxxx
MDCs
Note: Effective with v26.0, the titles for the DRG and MDC files were
renamed to msdrg3.vXXX, msdrg4.vXXX and msmdc.vXXX. The
“ms” prefix replaced the “hf” prefix.
Installing the software 2.5
Preliminary
Installing the current software product
07/17/09
Installed program functions
The installation places the three functions, shown in table 2–3, in the
MS Grouper with Medicare Code Editor folder off Programs in the
Start menu on your PC.
Table 2–3. Installed program functions
Function
When to select the function
Interactive
Select to display the MS Grouper with Medicare
Code Editor Software interactive data entry window.
MS-DOS prompt
Select to display a window containing a MS-DOS
prompt to process records with batch processing.
Note: If the MS-DOS prompt window does not
appear when you select this function, verify that the
environment path includes C:\WINDOWS\system32.
If necessary, add it to the path.
Readme
Accessing the functions
Select to read product-specific information for the
current release.
To access any of the functions in table 2–3:
❑
Go to the Start menu.
❑
Select Programs > MS Grouper with Medicare Code Editor
Software.
❑
Select the appropriate function.
❑
For information on interactive claims processing, go to
chapter 3.
— or —
For information on batch processing, go to chapter 4.
2.6 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Uninstalling grouper versions
If you need to uninstall an earlier grouper version of the software,
you can run the uninstall process.
❑
Launch the uninstall process from the Windows Control Panel
or from the product directory.
◆
To launch the uninstall process from the Control Panel,
— Click the Start menu and select Settings > Control Panel >
Add or Remove Programs.
— From the list of installed products, select MS Grouper with
Medicare Code Editor Software.
— Click Change/Remove.
◆
To launch the uninstall process from the product directory,
— Locate the product directory. The default directory is C:\Program Files\MSG MCE Software.
— Open the folder named Uninstall_MS Grouper with Medicare Code Editor Software, then select Uninstall MS Grouper
with Medicare Code Editor Software.exe.
❑
On the Uninstall MS Grouper with Medicare Code Editor
Software screen, read the message summarizing the uninstall
process, then click Next.
❑
On the Uninstall Options screen, select Complete Uninstall to
uninstall all software versions.
— or —
Select Uninstall Specific Features to uninstall selected versions.
❑
Click Next.
◆
If you chose Complete Uninstall, the uninstall process begins.
◆
If you chose Uninstall Specific Features, the Choose Product
Features screen appears. On this screen, select the grouper versions you want to remove, then click Uninstall.
The Uninstall MS Grouper with Medicare Code Editor Software
screen appears and the uninstall process begins. When the process is
finished, the Uninstall Complete screen appears.
❑
October 2009
On the Uninstall Complete screen, click Done.
Installing the software 2.7
07/17/09
2.8 MS Grouper with Medicare Code Editor Software
Preliminary
October 2009
Preliminary
07/17/09
Chapter 3
Interactive data processing
3
07/17/09
Contents
Interactive data processing
Data entry
Preliminary
3.3
3.4
Grouper selection 3.4
Steps for entering data 3.4
Data entry fields 3.7
Data entry menu options 3.11
Data entry command buttons 3.11
Interactive error messages 3.12
Program output
3.13
Viewing interactive output 3.16
Exiting the report window 3.16
Output report fields 3.17
Output report menu options 3.21
Output report command button 3.22
Program edits
3.2 MS Grouper with Medicare Code Editor Software
3.23
October 2009
Preliminary
07/17/09
Chapter 3
Interactive data processing
THE MEDICARE SEVERITY GROUPER with Medicare Code
Editor (MSG/MCE) software processes medical record data by two
methods:
◆
Interactively entering one record at a time;
◆
By batch, processing data from a group of records entered in an
MS-DOS file.
This chapter discusses the interactive method of claim processing.
Interactive processing enables you to correct invalid data or codes at
the time a record is processed. This method uses a Windows environment to enter data and view the output.
Sections in this chapter give you information on:
October 2009
◆
Data entry, including field descriptions, information on menus
and command buttons on the data entry window, and error
messages.
◆
Program output, including an example output report and explanation of output fields, information on menus and command
buttons on the data output window.
◆
Descriptions of the edits in the MSG/MCE software program.
Interactive data processing 3.3
07/17/09
Preliminary
Data entry
The information gives you field information and valid entry ranges
where they exist, to assist in data entry. You will be able to navigate
through the data entry window and perform functions, such as editing
fields or copying text. Error messages that can occur during data
entry are listed and explained.
Grouper selection
As you enter data, the program automatically selects the appropriate
grouper for processing using the discharge date entered from the
patient’s medical record. For example, a discharge date of 11/14/2008
will call MS grouper 26 with an effective date range of 10/01/
2008–09/31/2009 to process the claim. If the discharge date is 10/01/
2009 or later, MS grouper 27.0 is used.
If the discharge date of the patient is not within an effective date
range for any installed grouper, or if the discharge date is missing, the
program defaults to the current version. In that case, this message is
displayed on the output report:
Grouper version [current #] will be used because the discharge date is either missing
or is outside the effective date range for the installed groupers.
Steps for entering data
❑
Follow these steps for interactive data entry:
From the Start menu, select Programs > MS Grouper with Medicare Code Editor Software > Interactive.
The About box window appears briefly followed by the data entry (or
input) window titled, MS Grouper with Medicare Code Editor Software, shown in figure 3–1.
The data entry window is organized into three sections:
◆
Patient Information
◆
Patient Stay Information
◆
Codes
The cursor will be positioned at the first field. To enter data, you can
either tab or press Enter to move through fields, or click in a field.
Text will appear below the code tables displaying the location of the
cursor.
3.4 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Data entry
Title bar
Menus
Sections
Command
buttons
Figure 3–1. Data entry window
❑
Enter data into the appropriate fields.
If you need assistance when working on the data entry window, table
3–1 contains information to help you.
October 2009
Interactive data processing 3.5
Data entry
07/17/09
Preliminary
Table 3–1. Help for interactive data entry
What do you want to do?
Help
Find specific data entry field information
Go to table 3–2 on page 3.7.
Work with text on the window
Use standard Windows options (e.g., cut, copy, paste).
Make a menu selection
Go to table 3–3 on page 3.11.
Correct an entry
Simply highlight and overwrite the entry with the correct
information.
Delete a code entry row
For the Admit Dx, highlight the code and press the Delete
key. For other codes, click on the number of the row to
highlight it, then use the Edit > Delete option.
For more information, see the Diagnoses and Procedures
field descriptions in table 3–2; also see tables 3–3 and 3–4
for additional information on the Delete and Clear functions.
View a long field description or edit message
associated with a code
Use the scroll bar.
Eliminate an error message
Select OK to close the dialog box, and correct the problem.
The “Interactive error messages” section on page 3.12 lists
error messages that can occur with their descriptions.
❑
When you have completed data entry for a record, select Report
to view the processed record.
You can select Report by clicking on it, or by tabbing to it and then
pressing Enter.
The “Viewing interactive output” section on page 3.15 contains output information, including printing of the report. An example of an
output report is shown on page 3.14.
3.6 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Data entry fields
Data entry
Table 3–2 describes the fields on the data entry window. An asterisk
(*) indicates a required field.
Table 3–2. Data entry fields
Field name
Length Description
Patient information
Name
31
Name of the patient. Alphanumeric. First and last names can be entered in any
order.
Medical record number
13
Patient’s medical record number. Alphanumeric.
Birth date
10
Birth date of the patient. Format: mm/dd/yy, mm/dd/yyyy, mmddyyyy, or
mmddyy.
A dash (-), slash (/), period or space is accepted to separate any digit from 0–9.
The program automatically converts a two-digit year to a four-digit display. If the
patient is more than 99 years of age, a four-digit year is required. A birth date
prior to 01/01/1883 can not be entered.
The birth and admit dates are used to calculate the age of the patient;
calculated age overrides entered age.
Age in years*
3
Age of the patient. Valid values: 0–124 years. Age can be an entered or a
calculated value. For more information, see the Birth date field description.
Sex*
1
Patient gender. Select a value from the drop-down list:
0, u, U = Unknown
1, m. M = Male
2, f, F = Female
Account number
17
Patient account number. Alphanumeric.
Primary payer
2
Primary payer for the service provided. Select a value from the drop-down list:
01 Medicare (default)06
Blue Cross
02 Medicaid 07
Insur Co
03 Title V
08
Self Pay
04 Other Govt 09
Other
05 Work Comp10
No Charge
Admit date
10
Date of admission to the facility. Format: mm/dd/yy, mm/dd/yyyy, mmddyyyy, or
mmddyy.
A dash (-), slash (/), period or space is accepted to separate any digit from 0–9.
The program automatically converts a two-digit year to a four-digit display.
Patient Stay information
The birth and admit dates are used to calculate the age of the patient; for more
information, see the Birth date field description. The admit and discharge dates
are used to calculate length of stay (LOS); calculated LOS overrides entered
LOS.
October 2009
Interactive data processing 3.7
Data entry
07/17/09
Preliminary
Table 3–2. Data entry fields (continued)
Field name
Length Description
Discharge date
10
Date of discharge from the facility. Format: mm/dd/yy, mm/dd/yyyy, mmddyyyy,
or mmddyy.
A dash (-), slash (/), period or space is accepted to separate any digit from 0–9.
The program automatically converts a two-digit year to a four-digit display.
The discharge date determines the grouper version called to process the
record. The discharge date also determines which discharge status codes are
displayed. For this reason, we recommend entering the discharge date before
discharge status (see also Discharge status, below).
An error message is displayed when you click Report, and the discharge date
field is blank or contains a date outside the effective date range of any installed
grouper; Click OK to accept the default (current) grouper version to process the
claim, or Cancel to enter a discharge date. When you accept the default
version, the output report includes a USED BY DEFAULT notation.
The discharge and admit dates are used to calculate LOS; for more
information, see the Admit date field description.
3.8 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Data entry
Table 3–2. Data entry fields (continued)
Field name
Length Description
Discharge status*
2
Status of discharge. Enter the discharge date before entering the discharge
status so that the appropriate discharge status codes are displayed in a
drop-down list (see also Discharge date, above). An error message is displayed
when a discharge status is selected first and is invalid for a discharge date
entered afterward (see “Interactive error messages” on page 3.12).
All available discharge status codes are listed below.
01 = Home or self-care
02 = Disch/trans to another short term hosp
03 = Disch/trans to SNF
04 = Disch/trans to ICF
05 = Disch/trans to another type of facility (valid until 03/31/08)
05 = Disch/trans to a designated cancer center or children’s hospital
(revised 04/01/08)
06 = Care of home health service
07 = Left against medical advice
08 = Home IV service (deleted 10/01/05)
20 = Died
21 = Disch/trans to court/law enforcement
30 = Still a patient
43 = Fed hospital (added 10/01/03)
50 = Hospice-home
51 = Hospice-medical facility
61 = Swing Bed (added 10/01/2001)
62 = Rehab fac/unit (added 10/01/2001)
63 = LTC hospital (added 10/01/2001)
64 = Nursing facility–Medicaid certified (added 10/01/02)
65 = Psych hosp/unit (added 10/01/03)
66 = Critical access hospital (added 10/01/05)
70 = Disch/trans to another type of health care institution not defined elsewhere
in the code list (added 04/01/08)
71 = OP services-other facility (10/01/01–09/30/03 only)
72 = OP services-this facility (10/01/01–09/30/03 only)
LOS (length of stay)
3
Number of days the patient was in the facility. Valid entries: 000–999.
LOS can be user-entered, or calculated when admit and discharge dates have
been entered. For more information, see the Admit date field description.
Optional information
72
Comments or other user-specified information. Alphanumeric.
5
Enter an ICD-9-CM diagnosis code without decimals. Lower case is
automatically converted to upper case. The code description is displayed as
you type the code. If the code is invalid, an error message is displayed.
Codes
Admit Dx*
Note: Only diagnosis codes of up to five digits are currently accepted by the
interactive program.
October 2009
Interactive data processing 3.9
Data entry
07/17/09
Preliminary
Table 3–2. Data entry fields (continued)
Field name
Length Description
Apply HAC
(hospital-acquired
condition) logic
1
Diagnoses:
7
PDX (principal diagnosis)*
Diagnoses 2–25
The checked box indicates that HAC logic will be applied. By default, this box
will always be checked.
Enter ICD-9-CM diagnosis codes without decimals. Lower case is automatically
converted to upper case. The code description and any applicable edits are
displayed as you type the code. A maximum of 25 codes can be entered.
Pressing the Enter or Tab key at the first blank diagnosis code field moves
focus to the first blank procedure code field.
The Description and Edits fields are display only. A maximum of four edits per
code can be displayed (see table 3–9 for a list of code edits).
If you enter a secondary diagnosis and later delete it, the program moves up
the diagnoses following the deleted row, if there are any, to fill in the empty row.
This behavior does not apply to the principal diagnosis.
Note: Only diagnosis codes of up to five digits are currently accepted by the
interactive program.
Present on Admission
Indicators
1
Enter one of the following Present on Admission Indicators, required for a
diagnosis other than the admit diagnosis:
Y= Yes, present at the time of inpatient admission
N = No, not present at the time of inpatient admission
U = Insufficient documentation to determine if present on admission
W= Clinically unable to determine if present at time of admission
1= Exempt from reporting
Procedures:
PP (principal procedure)
Procedures 2–25
7
Enter ICD-9-CM procedure codes without decimals. Lower case is
automatically converted to upper case. The code description and any
applicable edits are displayed as you type the code. A maximum of 25 codes
can be entered. Pressing the Enter or Tab key at the first blank procedure code
field moves focus to the Report button.
The Description and Edits fields are display only. A maximum of four edits per
code can be displayed (see table 3–9 for a list of code edits).
If you enter a secondary procedure and later delete it, the program moves up
the procedures following the deleted row, if there are any, to fill in the empty
row. This behavior does not apply to the principal procedure.
Note: Only procedure codes of up to four digits are currently accepted by the
interactive program.
3.10 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Data entry menu options
Data entry
Table 3–3 describes the menu options on the data entry window. Use
the Function column to locate the task you want to perform. Accelerator keys allow you to bypass a menu and activate a function more
quickly.
Table 3–3. Data entry menu items
Menu
Item
Function
Accelerator
key
Patient
(Alt + P)
New
Displays the demographics tab
cleared of all previously entered
information.
Ctrl+N
Exit
Exits the program.
Alt+F4
Cut
Removes the selected text and
copies it to the clipboard.
Ctrl+X
Copy
Copies the selected text to the
clipboard.
Ctrl+C
Paste
Inserts contents of the clipboard
at the insertion point.
Ctrl+V
Delete
Deletes the selected text, or the
selected row in the Codes
section.
Delete
About
Displays the About box with
current version information.
Edit
(Alt + E)
Help
(Alt + H)
Data entry command buttons
Table 3–4 describes the command buttons on the data entry window.
Use the Function column to locate the task you want to perform.
Table 3–4. Data entry command buttons
Button
Function
Clear
Clears all diagnosis (including admit dx) and procedure
code entries and their descriptions, and any associated
edits. You must click Clear to activate its function;
tabbing to the button and pressing Enter will not work.
Report
Displays a pre-formatted output report that can be
printed or saved.
An error message displays in place of the report when
the format of an entered date is invalid format; correct
the format, and click Report again.
Data output is discussed on page 3.13.
October 2009
Interactive data processing 3.11
Data entry
Interactive error messages
07/17/09
Preliminary
Table 3–5 is an alphabetical list of the error messages that can occur
during data entry. The messages help prevent invalid or incorrect
entries.
Table 3–5. Interactive error messages
Message
Description
Admit date cannot be after Discharge date.
The program checks for logical sequencing of dates.
[Admit date] [Birth date] [Discharge date]
[Procedure date] cannot be after today’s date
The date entered in the date field is after the system (today’s)
date.
Admit date cannot precede Birth date.
The program checks for logical sequencing of dates.
[Admit date] [Birth date] [Discharge date] is
invalid. Dates must be entered in this format: mm/
dd/yyyy, mm/dd/yy, mmddyyyy, or mmddyy.
The value entered for the month, day or year is outside the valid
range. See table 3–2 for more information on date fields.
Admit diagnosis is a required field. Please enter
an admit diagnosis code.
The program does not process a record with a blank required
field.
Age is invalid. Calculated age must be between 0
and 124 years.
The valid range for age in years is 0–124.
Birth date cannot be after Admit date.
The program checks for logical sequencing of dates.
Birth date cannot be after Discharge date.
The program checks for logical sequencing of dates.
Discharge date cannot precede Admit date.
The program checks for logical sequencing of dates.
Discharge date cannot precede Birth date.
The program checks for logical sequencing of dates.
Discharge status invalid for discharge date
entered.
When the discharge status is entered before the discharge date,
and the discharge status is invalid for the entered discharge
date, this message is displayed. To avoid this message, enter
the discharge date before selecting a discharge status.
Length of stay (LOS) is invalid. Calculated length
of stay must be between 0 and 999 days.
The entered or calculated LOS exceeds the upper limit allowed
for the field.
The following required fields are missing
and/or invalid:
Age in years
Sex
Discharge status
Admit Dx
PDX
Discharge date
You can not produce an output report when a required field
contains invalid data or is blank. The program sets the focus to
the first invalid or blank required field.
3.12 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Program output
The information in this section describes the output resulting from
the processing of the data entered interactively into the program. The
output is displayed on your computer screen and can be printed, copied, or saved to a text file.
Reports are saved singly, that is, the program does not append them.
If you want a file of multiple reports, you can create one by copying
several output reports, one at a time, and pasting them into a text file.
Once data is erased from the data entry window and the Report window closed, the output is no longer available unless you re-enter the
data.
This section also contains an illustration of an output report and
information on the report fields. Program edits are explained in the
following section.
❑
To display the output report, select Report on the data entry window (figure 3–1).
You can select Report by clicking on it, or by tabbing to it and then
pressing Enter.
A sample report is shown in figure 3–2 and contains the following
elements:
◆
A title line giving the version of the grouper that processed the
claim.
◆
Patient information copied from the entries you made on the data
entry window.
◆
Grouper information: the assigned MDC, Final DRG, and Final
DRG cost weight.
◆
Hospital-acquired condition (HAC) status message.
◆
Clinical information: a listing of the entered diagnosis and procedure codes with their English descriptions.
◆
Present on Admission (POA) indicators for diagnosis codes, as
applicable.
◆
Edits for diagnosis and procedure codes, as applicable.
◆
Initial DRG.
The DRG cost weight represented by xx.xxxx in the sample report
will be replaced by the actual current cost weight for the assigned
DRG.
October 2009
Interactive data processing 3.13
Program output
07/17/09
Title line
MS-DRG Assignment with Medicare Code Editor V27.0
Patient
information
Patient name: Jane Smith Medical rec #: 1054879
Preliminary
Admit date: 10/01/2009 Discharge date: 10/06/2009 Birth date: 09/09/1943
Optional information:
Patient acct #: 458799
Age in years: 65 Sex: Female
Discharge status: 01 Home or self-care
Grouping
information
Clinical
information
MDC: 10 Endocrine, nutritional & metabolic diseases & disorders
Final
DRG: 639 Diabetes w/o CC/MCC
Cost weight: 00.6742
MS-DRG Grouper version 27.0 (October 1, 2009) used.
HAC Status: Evaluated - with demotion and DRG changes.
Admitting Diagnosis:
25001 DMI wo cmp nt st uncntrl
Principal Diagnosis:
25001 DMI wo cmp nt st uncntrl (DRG)
POA: Yes, present at the time of inpatient admission
Secondary Diagnoses:
Edit
25001 DMI wo cmp nt st uncntrl
POA: Yes, present at the time of inpatient admission
Edit: Duplicate of principal diagnosis (MCE)
POA indicator
99664 React-indwell urin cath (DRG)(HAC)
POA: No, not present at the time of inpatient admission
5990
Urin tract infection NOS (DRG)(HAC)
POA: No, not present at the time of inpatient admission
4019
Hypertension NOS
POA: Yes, present at the time of inpatient admission
6069
Male infertility NOS
POA: Yes, present at the time of inpatient admission
Edit: Sex conflict (MCE)
No procedures performed
Initial
DRG: 638 Diabetes w CC
Primary Payer: 01 Medicare
Actual LOS: 5
Patient Summary Edits:
MCE pre-payment errors only
Figure 3–2. Sample output report
3.14 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Viewing interactive output
Program output
Output report fields are described in table 3–6 on page 3.16.
Use the menu options described in table 3–7 on page 3.20 to:
◆
Print the output report
◆
Copy part or all of the report
◆
Save the report to a file
The output report is read-only. To change data on the output report,
close the report window and return to the data entry window, edit
information there and re-generate the report.
Exiting the report window
❑
With the output report displayed on your screen:
Select Close at the bottom of the report window.
The data entry window is re-displayed. You can:
◆
Edit the data for the current record shown.
— or —
◆
October 2009
Select Patient > New to begin data entry for a new record.
Interactive data processing 3.15
Program output
07/17/09
Output report fields
Preliminary
Table 3–6 describes the fields on the output report.
Table 3–6. Interactive output report fields
Name
Description
Patient name
Medical record number
Admit date
Discharge date
Optional information
Patient account number
Age in years
Sex
Discharge status
These output fields carry over the data entry information.
See table 3–2 on page 3.7 for information on these fields.
3.16 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Program output
Table 3–6. Interactive output report fields (continued)
Name
Description
Grouping information
(MDC, final DRG, final
cost weight, grouper
version used)
The Major Diagnostic Category (MDC) and Final Diagnosis Related Group (DRG)
assigned to the record based on the age, sex, discharge status, Hospital Acquired
Conditions (HAC), Present on Admission (POA) indicators, and codes entered from the
record. The MS-designated DRG cost weight shows under the DRG line. For a list of
DRGs and associated cost weights in the current version of the MS grouper, see
appendix A.
Patient records assigned to DRGs 998 (Principal diagnosis invalid as discharge
diagnosis) or 999 (Ungroupable) may not have an assigned valid MDC. In this case, no
MDC number or description is displayed.
When DRG 999 is assigned, one of the following messages identifies the reason why the
record is ungroupable:
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
Invalid principal diagnosis
Invalid age (<0 or >124)
Invalid discharge date
Invalid sex (not 1 or 2)
Invalid discharge status (batch only)
Record does not meet criteria for any DRG
Illogical principal diagnosis
Diagnosis code can not be used as principal diagnosis
Invalid principal diagnosis
POA logic nonexempt - HAC-POA(s) invalid or missing. *Long description: POA logic
Indicator = Z AND at least one HAC POA is invalid or missing *Batch only
POA logic invalid/missing - HAC-POA(s) are N, U. *Long description: POA logic
Indicator is invalid or missing AND at least one HAC POA is N or U *Batch only
POA logic invalid/missing - HAC-POA(s) invalid/missing. *Long description: POA logic
Indicator is invalid or missing AND at least one HAC POA is invalid or missing *Batch
only
POA logic nonexempt - HAC-POA(s) are 1. *Long description: POA Logic Indicator =
Z AND at least one HAC POA =1 *Batch only
POA logic invalid/missing - HAC-POA(s) are 1. *Long description: POA Logic
Indicator is invalid or missing AND at least one HAC POA = 1 *Batch only
POA logic nonexempt - multiple distinct HAC-POA not Y,W,N,U. *Long description:
POA Logic Indicator = Z AND there are multiple HACs that have different HAC POA
values that are not Y, W, N, U *Batch only
POA logic invld/mssng - multiple distinct HAC-POAs not Y,W. *Long description: POA
Logic Indicator is invalid or missing AND there are multiple HACs that have different
HAC POA values that are not Y or W *Batch only
The version of the grouper used for grouping is displayed with the effective date
associated with the grouper. If you default to the current grouper version when the
discharge date is invalid or missing (see page 3.9 for discharge date information), the
output states USED BY DEFAULT.
October 2009
Interactive data processing 3.17
Program output
07/17/09
Preliminary
Table 3–6. Interactive output report fields (continued)
Name
Description
Clinical information
Displayed codes include admit diagnosis, principal diagnosis, secondary diagnoses, and
procedures. Descriptions follow the codes and, if applicable, the following indicators:
DRGIndicates a secondary diagnosis or procedure used to determine DRG
assignment. A secondary diagnosis code assigned with HAC and DRG
indicates a DRG change with demotion. A procedure code assigned with
HAC and DRG indicates code was used for the definition of HAC.
HACIndicates a code flagged as a Hospital Acquired Condition.
MCCIndicates a diagnosis code considered to be a major complication or
co-morbidity. An MCC diagnosis can significantly influence DRG assignment.
When more than one MCC code is present, a DRG indicator replaces the
MCC indicator to mark the MCC code used to determine DRG assignment.
CCindicates a diagnosis code considered to be a complication or co-morbidity. A CC
diagnosis can significantly influence DRG assignment. When more than one
CC code is present, a DRG indicator replaces the CC indicator to mark the
CC code used to determine DRG assignment.
ORIndicates a procedure code that normally requires use of an operating room
and which can significantly influence DRG assignment. When more than
one OR code is present, DRG replaces OR to mark the OR code used
to assign the DRG.
Present on Admission
(POA) information
Indicates whether the diagnosis was present at the time the patient was admitted.
Edit information
Program edits that indicate a possible coding problem are displayed under the codes that
generated them. Each edit includes a Medicare Code Editor notation (MCE). A maximum
of four edits per code will be displayed. See table 3–9 for a description of each edit and
why they occur.
Initial DRG
Initial Diagnosis Related Group (DRG) assignment prior to Hospital Acquired Condition
logic grouper processing.
Primary payer
LOS
These output fields carry over the data entry information.
See table 3–2 on page 3.7 for information on these fields.
3.18 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Program output
Table 3–6. Interactive output report fields (continued)
Name
Description
Patient summary edits
This section is where clinical edits and data entry error messages not pertaining to a
specific code are displayed. The Invalid sex edit is currently the only edit that could
display in this section.
Edits are flagged as pre-payment or post-payment errors, noted as one of the following:
MCE pre-payment errors only
MCE post-payment errors only
MCE pre- and post-payment errors
No MCE pre- or post-payment errors
For this flag, edits are categorized as follows:
Pre-payment
Age conflict
Duplicate of principal diagnosis
E-code as principal diagnosis
Invalid ICD-9-CM code
Manifestation code as principal diagnosis
Non-covered procedure
Questionable admission
Sex conflict
Unacceptable principal diagnosis/Requires secondary diagnosis
Invalid sex
Limited coverage
Wrong procedure performed
Post-payment
Open biopsy check
Bilateral procedure
Non-specific diagnosis (discontinued 10/01/07)
Non-specific O.R. procedure (discontinued 10/01/07)
MSP alert (discontinued 10/01/01)
October 2009
Interactive data processing 3.19
Program output
Output report menu options
07/17/09
Preliminary
Table 3–7 describes the menu options on the output report window.
Use the Function column to locate the task you want to perform.
Accelerator keys allow you to bypass a menu and activate a function
more quickly.
Table 3–7.
Output report menu items
Menu
Item
Function
Accelerator
key
File
(Alt + F)
Print
Prints the output report.
Ctrl+P
Save As
Opens a Save As dialog box to
save the currently displayed
output report as a text file. Unless
you specify otherwise, the
filename will be report.txt, and the
file will be saved in the directory
where the product was installed.
Unless you specified otherwise at
the time of installation, this
directory is C:\Program
Files\CMS\CMSG MCE Software.
You can browse and save the file
in any directory you choose.
Ctrl+S
Records can not be appended in
the report.txt file. The file is
overwritten each time you save a
report unless you specify a
different filename. The program
asks if you want to overwrite the
report.txt file before proceeding
with the save.
Edit
(Alt + E)
Exit
Closes the output report and
Ctrl+Q
re-displays the data entry window.
Copy
Copies the selected text to the
clipboard.
Ctrl+C
Select All
Selects the entire output report.
Ctrl+A
3.20 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Output report command
button
Program output
Table 3–8 describes the command button on the output report window. Use the Function column to locate the task you want to perform.
Table 3–8. Output report command button
October 2009
Button
Function
Close
Closes the output report and re-displays the data entry
window.
Interactive data processing 3.21
Program edits
07/17/09
Preliminary
Program edits
The MCE edits in MSG/MCE software are described in this section.
Table 3–9 lists the edits and where the edit is activated. Edits can
appear on the interactive data entry window in the Codes section, and
on program output under the codes that generated them.
Table 3–9. Program edits
Message
Description
Diagnosis codes
Age conflict
Some diagnoses are unlikely for specific ages (e.g., a 5-year old with prostatic
hypertrophy). Codes can be assigned to four age categories:
Newborn - age of 0 years
Pediatric - age 0–17 years inclusive
Maternity - age 12–55 years inclusive
Adult - age 15–124 years inclusive
Duplicate of principal diagnosis
When the same code is entered as the principal and a secondary diagnosis,
this edit appears after the secondary diagnosis code. If the code happens to
be on the CC list, the DRG assignment could be affected.
E-code as principal diagnosis
E-codes describe circumstances causing an injury and not the nature of the
injury, and should not be used as a principal diagnosis.
Invalid ICD-9-CM code
The code is not in the list of valid codes and is assumed to be invalid or have a
missing digit. A record with an invalid principal diagnosis code is assigned to
DRG 999, Ungroupable.
Manifestation code as principal
diagnosis
A manifestation code describes an underlying disease, not the disease itself,
and should not be used as a principal diagnosis.
Secondary payer alert (MSP alert)
Certain trauma-related codes may indicate that another type of liability
insurance should be the primary payer rather than Medicare.
Note: This edit was discontinued on 10/01/2001 and will be displayed in MSG/
MCE software versions 16.0–18.0 only.
Non-specific principal diagnosis
Some codes, especially “not otherwise specified” (NOS) codes, are valid but
are not suitably specific for a principal diagnosis. This edit applies only if the
patient is discharged alive since a more complete diagnostic work-up might
not have been possible for a patient who has died.
Note: This edit was discontinued on 10/01/2007 and will be displayed in MSG/
MCE software versions 16.0–24.0 only.
Questionable admission
Some diagnoses are not usually considered sufficient justification for
admission to an acute care facility (e.g., benign hypertension).
Sex conflict
Some codes are specific to gender. The edit indicates when such a code
indicates a diagnosis (e.g., maternity) inconsistent with the gender of the
patient (male).
3.22 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table 3–9. Program edits (continued)
Message
Description
Unacceptable principal diagnosis
Selected codes describe a circumstance that influences an individual’s health
status but is not the current injury or illness. These codes should not be used
as a principal diagnosis.
Requires secondary diagnosis
However, some codes otherwise considered as unacceptable are accepted if
any secondary diagnosis is present (e.g., a V-code for physical therapy
requires a secondary diagnosis). If no secondary diagnosis is present for
these codes, the Requires secondary diagnosis message will appear.
Wrong procedure performed
Certain E-codes indicate that the wrong procedure was performed. This edit
indicates that one of these E-codes is present.
Procedure codes
Bilateral procedure
Codes may not accurately reflect procedures performed on two or more
different bilateral joints of the lower extremities during the same admission.
The software indicates that the coded bilateral procedure may actually have
been two procedures done on a single joint (e.g., a total hip replacement with
a partial hip replacement will generate the edit while two total hip
replacements will not).
Invalid ICD-9-CM code
The code is not in the list of valid codes and is assumed to be invalid or have a
missing digit.
Limited coverage
For certain procedures whose medical complexity and serious nature incur
extraordinary associated costs, Medicare limits coverage to a portion of the
cost. The limited coverage edit is generated on claims containing any of the
procedures listed below.
Lung volume reduction surgery (LVRS)
Lung transplant
Combination heart/lung transplant
Heart transplant
Implantable heart assist system
Intest/multi-visceral transplant
Liver transplant
Kidney transplant
Pancreas transplant
Artificial heart transplant
The edit message indicates the type of limited coverage (e.g., Heart
transplant-Limited coverage, Lung transplant-Limited coverage, etc.)
Non-covered procedure
Some procedures are not covered by Medicare payment.
Non-specific O.R. procedure
Some codes, especially NOS (not otherwise specified) codes, are valid but are
not suitably specific. This edit applies only if all coded O.R. procedures are
considered non-specific.
Note: This edit was discontinued on 10/01/2007 and will be displayed in MSG/
MCE software versions 16.0–24.0 only.
October 2009
Interactive data processing 3.23
Program edits
07/17/09
Preliminary
Table 3–9. Program edits (continued)
Message
Description
Open biopsy check
(If not open biopsy, code XXXX)
Surgical biopsies are called open biopsies and are relatively infrequent. A
different DRG is assigned depending on whether or not the biopsy was open.
There are specific ICD-9-CM codes for open and non-open biopsies. The
software identifies all open biopsy codes, suggesting an alternate code
(XXXX) if the procedure was a closed biopsy.
Sex conflict
Some codes are specific to gender. The edit indicates when a procedure code
(e.g., prostatectomy) is inconsistent with the gender of the patient (female).
Invalida
Invalid age
A patient’s age is usually necessary for appropriate DRG determination. If the
age is not between 0 and 124 years, the age is assumed to be in error.
Invalid sex
A patients sex is sometimes necessary for appropriate DRG determination.
The sex code reported must be either 1 (male) or 2 (female).
Invalid discharge status
A patient’s discharge status is sometimes necessary for appropriate DRG
determination. Discharge status must be coded according to the UB–04
conventions (see page 3.9 for a list of valid entries).
a. Of the three invalid edits, only the invalid sex edit will be shown in the Patient Summary Edits section for interactive
on the output report. For batch, all three invalid edits will be shown in the Patient Summary Edit section on the
output report.
3.24 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Chapter 4
Batch processing
4
07/17/09
Contents
Batch processing
4.3
Steps in batch processing
Input file format
Preliminary
4.4
4.6
Command line processing options 4.10
Command line examples 4.11
Output file formats
4.12
Formatted output (-o option) 4.12
Upload file (-u option) 4.12
Working with batch output
Viewing output 4.18
Printing output 4.18
Renaming a file 4.18
4.18
Batch processing error messages
Log files
4.19
4.21
Viewing the file 4.22
Printing the file 4.22
Renaming the file 4.22
4.2 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Chapter 4
Batch processing
THE MEDICARE SEVERITY GROUPER with Medicare Code
Editor (MSG/MCE) software processes medical record data by two
methods:
◆
Interactively entering one record at a time;
◆
By batch, processing data from a group of records entered in an
MS-DOS file.
This chapter discusses the batch method of claim processing. Batch
processing enables you to process many records at a time by entering
data into an input file, and then running that file through the grouper.
This method uses an MS-DOS environment to run an input file and
to produce a file of formatted output reports and/or an upload file.
Sections in this chapter give you information on:
October 2009
◆
Steps to run batch processing
◆
Input and output file formats
◆
Processing options
◆
How to work with batch output
◆
Error messages
◆
Log files
Batch processing 4.3
07/17/09
Preliminary
Steps in batch processing
Figure 4–1 is a flow chart that shows the steps in processing records
in batch using the MSG/MCE software.
Create the input file
Input file format
Access the MS-DOS
prompt
Enter the batch processing commands
Batch processing
options
View output
Output file is generated
Output file format
Print output
Rename output
file
Figure 4–1. Batch processing overview
Follow these procedural steps to perform batch processing:
❑
Create the input file.
See the “Input file format” section on page 4.6 for detailed information on formatting the input field information.
❑
From the Start menu, select Programs > MS Grouper with Medicare Code Editor Software > MS-DOS prompt.
A window with the MS-DOS prompt is displayed.
4.4 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
❑
Steps in batch processing
At the prompt in the DOS window, type the batch processing
command line specifying the input file, the output that you want,
then press Enter.
The command line must contain:
◆
The executable command mce
◆
An input filename
◆
An output filename and/or an upload filename
For batch processing performance information, see table 4–1.
See page 4.10 for information on processing options and command
lines, including examples.
❑
If an error message is displayed on the screen and the program
ends, resolve the problem and run the process again.
See table 4–6 on page 4.19 for information on error messages that
can occur with their descriptions.
❑
View and/or print the output file.
See section “Working with batch output” on page 4.18 for more
information, if necessary.
Table 4–1. Batch processing performance information
Number of
records
File size (bytes)
Processing time
Input
Upload
Report
Both
50,000
41,703,753
63,305,697
56,576,085
1:59
500,000
417,037,530
633,056,970
565,760,845
27:15
5,000,000
4,170,375,300
6,330,569,700
5,657,608,450
4:29:17
This performance information is based on a computer with the following configuration:
October 2009
◆
CPU: Intel Xeon 5150 @2.66 Ghz
◆
Memory: 3.00 GB RAM
◆
OS: Microsoft Windows XP SP 2
Batch processing 4.5
07/17/09
Preliminary
Input file format
The batch input file is a single-line, fixed format consisting of sequential 832 character input records. Table 4–2 defines the record layout
for this format.
Table 4–2. Input file record layout
Field name
Position
Length
Occurrences
Patient name
1
31
1
Patient name. Alphanumeric. Left-justified, blank-filled. All
blanks if no value is entered.
Medical record
number
32
13
1
Medical record number. Alphanumeric. Left-justified,
blank-filled. All blanks if no value is entered.
Account number
45
17
1
Account number. Alphanumeric. Left-justified, blank-filled.
All blanks if no value is entered.
Admit date
62
10
1
Admit date. mm/dd/yyyy format. All blanks if no value is
entered. Used in age and LOS calculations.
Discharge date
72
10
1
Discharge date. mm/dd/yyyy. All blanks if no value is
entered. Used in LOS calculation.
4.6 MS Grouper with Medicare Code Editor Software
Description
October 2009
Preliminary
07/17/09
Input file format
Table 4–2. Input file record layout (continued)
Field name
Position
Length
Occurrences
Discharge status
82
2
1
UB-92 discharge status. Right-justified, zero-filled. Valid
values:
01 = Home or self-care
02 = Disch/trans to another short term hosp
03 = Disch/trans to SNF
04 = Disch/trans to ICF
05 = Disch/trans to another type of facility (valid until
03/31/08)
05 = Canc/child hosp (revised 04/01/08)
06 = Care of home health service
07 = Left against medical advice
08 = Home IV service (deleted 10/01/05)
20 = Died
21 = Disch/trans to court/law enforcement
30 = Still a patient
43 = Fed hospital (added 10/01/03)
50 = Hospice-home
51 = Hospice-medical facility
61 = Swing Bed (added 10/01/2001)
62 = Rehab fac/unit (added 10/01/2001)
63 = LTC hospital (added 10/01/2001)
64 = Nursing facility–Medicaid certified (added 10/01/02)
65 = Psych hosp/unit (added 10/01/03)
66 = Critical access hospital (added 10/01/05)
70 = Oth institution (added 04/01/08)
71 = OP services-other facility (10/01/01–09/30/03 only)
72 = OP services-this facility (10/01/01–09/30/03 only)
Primary payer
84
2
1
Primary pay source. Right-justified, zero-filled.
Valid values:
01 = Medicare
02 = Medicaid
03 = Title V
04 = Other Govt
05 = Work Comp
06 = Blue Cross
07 = Insur Co
08 = Self Pay
09 = Other
10 = No Charge
LOS
86
3
1
Length of stay. Right-justified, zero-filled. All blanks if no
value is entered. Calculated LOS overrides entered LOS.
Birth date
89
10
1
Birth date. mm/dd/yyyy format. All blanks if no value is
entered. Used in age calculation.
October 2009
Description
Batch processing 4.7
Input file format
07/17/09
Preliminary
Table 4–2. Input file record layout (continued)
Field name
Position
Length
Occurrences
Age
99
3
1
Age. Right-justified, zero-filled. All blanks if no value is
entered. Valid values: 0–124 years. Calculated age
overrides entered age.
Sex
102
1
1
Sex. Numeric. Valid values:
0 = Unknown
1 = Male
2 = Female
Admit diagnosis
103
7
1
Admit diagnosis. Left-justified, blank-filled. ICD-9-CM
diagnosis code without decimal. All blanks if no value is
entered.
Description
Note: Only diagnosis codes of up to five digits are
currently recognized as valid. When a code longer than
five digits is entered it will be blank filled through the
seventh position.
Principal diagnosis
110
8
1
Principal diagnosis. First 7 bytes left-justified, blank filled.
Eighth byte represents POA indicator.
See the note in the Admit diagnosis field above.
Secondary
diagnoses
118
8
24
Diagnoses. First 7 bytes left-justified, blank filled. Eighth
byte represents POA indicator. Up to 24 ICD-9-CM
diagnosis codes without decimals. First blank code ends
diagnosis processing.
See the note in the Admit diagnosis field above.
Principal Procedure
310
7
1
Procedure codes. Left-justified, blank-filled. ICD-9-CM
procedure code without decimal.
Note: Only procedure codes of up to four digits are
currently recognized as valid. When a code longer than
five digits is entered it will be blank filled through the
seventh position.
Secondary
Procedures
317
7
24
Procedure codes. Left-justified, blank-filled. Up to 24
ICD-9-CM procedure code without decimal.
See the note in the Principal Procedure field above.
4.8 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Input file format
Table 4–2. Input file record layout (continued)
Field name
Position
Length
Occurrences
Procedure date
485
10
25
For future use. Procedure dates. The format is mm/dd/
yyyy (for future use with POA logic.) Up to 25 procedure
dates accepted.
Apply HAC logic
735
1
1
Values X or Z to be captured for use with HAC logic.
These values reflect whether a hospital requires POA
reporting.
X = Exempt from POA indicator reporting
Z = Requires POA indicator reporting
Optional
information
736
72
1
Optional field. Left-justified, blank-filled. All blanks if no
value is entered.
Filler
808
25
1
Not used. Blank-filled.
October 2009
Description
Batch processing 4.9
07/17/09
Preliminary
Command line processing options
When processing a batch file, you must include specific options on
the command line to tell the program what file to process and what
type of output you want. Table 4–3 lists the available batch
processing options with their descriptions. Examples of command
lines follow the table.
When dealing with filenames and/or directories that include spaces,
you should quote the entire path including drive specifications, as
follows:
"C:/Program Files/MsgMce/Production/input file 1.txt"
➤
Note: When quoting directory paths that contain backslashes '\', the
backslashes need to be doubled as follows:
"C:\\Program Files\\MsgMce\\Production\\input file 1.txt"
The same rule applies to relative paths. For example, up two
directories to Production would be written as follows:
"..\\..\\Production\\"
Table 4–3. Batch processing options
Option
Description
-i
Use with the input filename. Required for all batch runs. The
name can not be the same as the output filename.
-o
Use with the output filename to create a formatted output
report. You must enter a filename. The name can not be the
same as the upload filename. If a file already exists with the
same name as the one you specify with the -o option, the
existing file will be overwritten. The -o option is not required
when the -u option is used.
-u
Specifies an single-line upload file without code descriptions.
You must enter a filename. The name can not be the same as
the output filename. If a file already exists with the same name
as the one you specify with the -u option, the existing file will
be overwritten. The -u option is required when there is no -o
option.
4.10 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Command line examples
Example 1
Result
Example 2
Result
Example 3
Result
October 2009
Command line processing options
Examples of batch processing commands are given below.
mce -i <input filename> -o <output filename>
Runs the specified input file and creates a formatted output report
file.
mce -i <input filename> -u <upload filename>
Runs the specified input file and creates a single-line upload file.
mce -i <input filename> -o <output filename> -u <upload filename>
Runs the specified input file and creates both a formatted output
report file and a single-line upload file.
Batch processing 4.11
07/17/09
Preliminary
Output file formats
The output from a batch run is determined by the option(s) you
entered on the command line. Table 4–4 describes the options.
Table 4–4. Batch processing output
Formatted output (-o option)
Option
Output created
-o
An output file of formatted reports
-u
An upload file of records without code descriptions
The file of formatted output reports generated with the -o option is
saved where the product was installed. Unless
you specified otherwise, this directory is: C:\Program Files\MSG
MCE Software. Figure 3–2 on page 3.14 is an example of an output
report. Note that optional information is displayed in the Optional
information field on the output report.
If you name the output file the same for every batch run, the file will
be overwritten during each run. To save an output file, rename it after
a batch run or specify a different name on the command line. The
“Renaming a file” section on page 4.18 contains instructions, if you
need them.
Upload file (-u option)
The file of records generated with the -u option is saved where the
product was installed. Unless you specified otherwise, this directory
is: C:\Program Files\MSG MCE Software.
If you name the upload file the same for every batch run, the file will
be overwritten during each run. To save an upload file, rename it
after a batch run or specify a different name on the command line.
The “Renaming a file” section on page 4.18 contains instructions, if
you need them.
The upload file consists of fixed-format, sequential 1266-character
output records. Table 4–5 defines the upload file record layout.
➤
Note: In previous versions of the software some unused fields had
zeros as placeholders. Starting with v26.0, please refer to the manual for field information, as a zero may have a different meaning.
4.12 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Output file formats
Table 4–5. Upload file record layout
Field name
MSG/MCE version
used
Position Length
Occurrences
Description
001
832
1
Input record
833
3
1
Version of the software used to process the claim. Rightjustified, blank-filled. Stored without decimal point.
Valid values: 270, 260, 251, 250, 240, 230, 220, 210, 200, 190,
180, 170, 160.
If the discharge date field is blank, invalid, or out of range of
versions loaded, the grouper defaults to the most current
version of the grouper installed and the term “used by default” is
displayed on output.
Initial DRG
836
3
1
Initial diagnosis related group. Right-justified, zero-filled.
Initial M/S indicator 839
1
1
Initial medical/surgical indicator.
0 = DRG return code was not zero
1 = Medical DRG
2 = Surgical DRG
Final MDC
840
2
1
Major diagnostic category. Right-justified, zero-filled.
Final DRG
842
3
1
Final diagnosis related group. Right-justified, zero-filled.
Final M/S indicator
845
1
1
Final medical/surgical indicator.
0 = DRG return code was not zero
1 = Medical DRG
2 = Surgical DRG
DRG return code
846
2
1
Numeric. Right-justified, zero-filled. Valid values:
0 = OK, DRG assigned
1 = Diagnosis code cannot be used as PDX
2 = Record does not meet criteria for any DRG
3 = Invalid age 4 = Invalid sex
5 = Invalid discharge status
10 = Illogical PDX
11 = Invalid PDX
12 = POA logic nonexempt - HAC-POA(s) invalid or missing
(batch only)
13 = POA logic invalid/missing - HAC-POA(s) are N, U (batch
only)
14 = POA logic invalid/missing - HAC-POA(s) invalid/missing
(batch only)
15 = POA logic nonexempt - HAC-POA(s) are 1 (batch only)
16 = POA logic invalid/missing - HAC-POA(s) are 1 (batch only)
17 = POA logic nonexempt - multiple distinct HAC-POA not
Y,W,N,U (batch only)
18 = POA logic invld/mssng - multiple distinct HAC-POAs not
Y,W (batch only)
October 2009
Batch processing 4.13
Output file formats
07/17/09
Preliminary
Table 4–5. Upload file record layout (continued)
Field name
Position Length
Occurrences
MSG/MCE edit
return code
848
1
4
Description
Right-justified, zero-filled. Valid values:
0000 = MCE - No errors found
0001 = MCE - Pre-payment error
0002 = MCE - Post-payment error
0003 = MCE - Pre- and post-payment errors
0004 = MCE - Invalid discharge status
See page 3.19 for information on which edits are classified as
pre- and post-payment errors.
Diagnosis code
count
852
2
1
Number of diagnosis codes processed. Right-justified,
zero-filled. This field does not include the admit diagnosis.
Procedure code
count
854
2
1
Number of procedure codes processed. Right-justified,
zero-filled.
4.14 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Output file formats
Table 4–5. Upload file record layout (continued)
Field name
Position Length
Occurrences
Principal diagnosis
edit return flag
856
8
1
Two-byte flag. Right-justified, zero-filled. A maximum of four
flags can be returned for each diagnosis code. Valid values:
01 = Invalid diagnosis code
02 = Sex conflict
03 = Not applicable for principal diagnosis
04 = Age conflict
05 = E-code as principal diagnosis
06 = Non-specific principal diagnosis (MCE versions 15.0–23.0
only)
07 = Manifestation code as principal diagnosis
08 = Questionable admission
09 = Unacceptable principal diagnosis
10 = Secondary diagnosis required
11 = Not applicable for principal diagnosis
12 = Code affected DRG assignment
13 = MSP alert (MCE versions 15.0–17.0 only)
15 = Diagnosis affected the final DRG only
16 = Diagnosis affected the initial DRG only
17 = Diagnosis is a MCC for initial DRG and a Non-CC for final
DRG
18 = Diagnosis is a CC for initial DRG and a Non-CC for final
DRG
19 = Wrong Procedure Performed
99 = Principal diagnosis part of HAC assignment criteria
Principal diagnosis
Hospital Acquired
Condition
assigned
864
2
1
Hospital Acquired Condition (HAC) assignment criteria
00 = Criteria to be assigned as an HAC not met
11 = Infection after bariatric surgery
Blank = Dx was not considered by grouper
Principal diagnosis
Hospital Acquired
Condition
866
1
1
Hospital Acquired Condition (HAC)
0 = HAC not applicable
1 = HAC criteria met
2 = HAC criteria not met
Secondary
diagnosis return
flag
867
8
24
Two-byte flag. Right-justified, zero-filled. A maximum of four
flags can be returned for each diagnosis code. Valid values:
01 = Invalid diagnosis code
02 = Sex conflict
03 = Duplicate of principal diagnosis
04 = Age conflict
11 = Secondary diagnosis is a CC
12 = Code affected DRG assignment
13 = MSP alert (discontinued 10/01/01)
14 = Secondary diagnosis is an MCC
19 = Wrong procedure performed
99 = Secondary diagnosis is a HAC
October 2009
Description
Batch processing 4.15
Output file formats
07/17/09
Preliminary
Table 4–5. Upload file record layout (continued)
Field name
Position Length
Occurrences
Secondary
diagnosis Hospital
Acquired Condition
assigned
1059
2
24
Hospital Acquired Condition (HAC) assigned
00 = Criteria to be assigned as an HAC not met
01 = Foreign object retained after surgery
02 = Air embolism
03 = Blood incompatibility
04 = Pressure ulcers
05 = Falls and trauma
06 = Catheter associated UTI
07 = Vascular catheter-associated infection
08 = Infection after CABG
09 = Manifestations of poor glycemic control
10 = DVT/PE after knee or hip replacement
11 = Infection after bariatric surgery
12 = Infection after certain orthopedic procedures of spine,
shoulder and elbow
Blank = Diagnosis was not considered by grouper
Secondary
diagnosis Hospital
Acquired Condition
1107
1
24
Hospital Acquired Condition (HAC)
0 = HAC not applicable
1 = HAC criteria met
2 = HAC criteria not met
Procedure edit
return flag
1131
8
25
Two-byte flag. Right-justified, zero-filled. A maximum of four
flags can be returned for each procedure code. Valid values:
01 = Invalid procedure code
02 = Sex conflict
12 = Code affected DRG assignment
15 = Procedure affected the final DRG assignment only
16 = Procedure affected the initial DRG assignment only
20 = Procedure is an OR procedure
21 = Non-specific OR procedure (MCE versions 15.0 - 23.0
only)
22 = Open biopsy check
23 = Non-covered procedure
24 = Bilateral procedure
30 = Lung volume reduction surgery (LVRS) - limited coverage
31 = Lung transplant - limited coverage
32 = Combo heart/lung transplant - limited coverage
33 = Heart transplant - limited coverage
34 = Implantable hrt assist - limited coverage
35 = Intest/multi-visceral transplant - limited coverage
36 = Liver transplant - limited coverage
37 = Kidney transplant - limited coverage
38 = Pancreas transplant - limited coverage
39 = Artificial Heart Transplant-Limit Coverage
99 = Procedure part of HAC assignment criteria
Description
4.16 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Output file formats
Table 4–5. Upload file record layout (continued)
Field name
Position Length
Occurrences
Procedure
Hospital Acquired
Condition
assigned
1331
2
25
Hospital Acquired Condition (HAC) assignment criteria
00 = Criteria to be assigned as an HAC not met
08 = Infection after CABG
10 = DVT/PE after knee or hip replacement
11 = Infection after bariatric surgery
12 = Infection after certain orthopedic procedures of spine,
shoulder and elbow
Blank = Procedure not considered by grouper
Initial 4-digit DRG
1381
4
1
Initial 4-digit DRG. Right-justified, zero-filled.
Final 4-digit DRG
1385
4
1
Final 4-digit DRG. Right-justified, zero-filled.
Final DRG CC/
MCE usage
1389
1
1
0 = DRG assigned is not based on the presence of CC or MCC
1 = DRG assigned is based on presence of MCC
2 = DRG assigned is based on presence of CC.
Initial DRG CC/
MCC Usage
1390
1
1
0 = DRG assigned is not based on the presence of a CC or
MCC
1 = DRG assigned is based on presence of MCC
2 = DRG assigned is based on presence of CC
Number of Unique
Hospital Acquired
Conditions Met
1391
2
1
The number of Unique Hospital Acquired Conditions that have
been met.
Hospital Acquired
Condition Status
1393
1
1
HAC Status
0 – HAC Status: Not Applicable
1 – HAC Status: One or more HAC criteria met; Final DRG
does not change
2 – HAC Status: One or more HAC criteria met; Final DRG
changes
3 – HAC Status: One or more HAC criteria met; Final DRG
changes to ungroupable
Cost Weight
1394
7
1
The DRG cost weight. This 7-byte field is displayed as 2 digits,
followed by a decimal point, followed by 4 digits.
newline
1401
2
1
End of record (carriage return/line feed). Not included on last
record.
October 2009
Description
Batch processing 4.17
07/17/09
Preliminary
Working with batch output
Output from batch processing can be viewed on your computer
screen or printed as hard copy. This section also tells you how to
rename a file so you can use the same output filename in the command line and not overwrite the records from a preceding run when
you process a new batch of input data.
Viewing output
❑
To view the formatted reports in the output file (using the -o option
on the command line):
At the system prompt in the directory where the file was created, enter:
type <filename> | more
This command displays the contents of the file, one screen at a time.
Press the space bar to advance through the file.
Printing output
❑
To print the contents of the output file:
At the system prompt in the directory where the file was created, enter:
print <filename>
Renaming a file
❑
To rename an output file:
At the system prompt in the directory where the file was created, enter:
rename <old filename> <new filename>
➤
Note: Please see performance table on page 4.5.
4.18 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Batch processing error messages
Table 4–6 is an alphabetical list of the error messages that can occur
during batch processing, and their outcomes.
➤
Note: When a potential for two processing option errors occurs, the
process option coupling takes precedence over the process option
duplication. Since (-i, -o, and -u) require a filename parameter, the
parameter is checked prior to a duplicate process option.
Example: mce -i -i inputfile -o outputfile [Error: Invalid option or its
value: -i is missing or has an invalid option.]
Example: mce -i inputfile -i anotherinput -o outputfile [Error: The
processing option (-i) should only be entered once.]
Table 4–6. Batch processing error messages
Message
Why it’s generated
What happens
Admit date cannot be after
discharge date
The program checks for logical
sequencing of dates.
The input record is processed and an
error message is written in the log
file.
Admit date is invalid
Any of the month, day, and year entries
are not in the valid ranges.
The input record is processed and an
error message is written in the log
file.
An input file (-i) must be specified
The required -i option is missing.
The message is displayed on the
screen and the program ends.
An output file (-o) or upload file (-u)
must be specified
At least one of the -o and -u options
must be specified.
The message is displayed on the
screen and the program ends.
Birth date cannot be after admit
date
The program checks for logical
sequencing of dates.
The input record is processed and an
error message is written in the log
file.
Birth date is invalid
Any of the month, day, and year entries
are not in the valid ranges.
The input record is processed and an
error message is written in the log
file.
Could not initialize run-time
environment
The message is displayed on the
screen and in the log file, and the
program ends.
Discharge date is invalid
Any of the month, day, and year entries
are not in the valid ranges.
The input record is processed and an
error message is written in the log
file.
Discharge status is invalid
The discharge status field entry is
invalid (see table 4–2 on page 4.6 for a
list of valid discharge status values).
The input record is processed and an
error message is written in the log
file.
October 2009
Batch processing 4.19
Batch processing error messages
07/17/09
Preliminary
Table 4–6. Batch processing error messages (continued)
Message
Why it’s generated
What happens
Error opening input file: <filename> The specified input file could not be
opened or is missing.
The message is displayed on the
screen and in the log file, and the
program ends.
Error opening output file:
<filename>
The specified output file could not be
opened.
The message is displayed on the
screen and the program ends.
Error reading input file: <filename>
The specified input file could not be
read.
The message is displayed on the
screen and in the log file, and the
program ends.
Input filename must be different
than the output filename
The same name is used for the input
and output files located in the same
directory.
The message is displayed on the
screen and the program ends.
Invalid age
The age field entry is invalid.
The input record is processed and an
error message is written in the log
file.
Invalid option or its value: <entered
value>
An argument was entered without a
processing option or a processing
option without an argument.
The message is displayed on the
screen and the program ends.
Invalid length of stay
The entered or calculated LOS exceeds
the upper limit allowed for the field (999
days).
The input record is processed and an
error message is written in the log
file.
Invalid processing option: <entered
value>
An option entered on the command line
is not valid.
The message is displayed on the
screen and the program ends.
Invalid sex
The sex field entry is invalid.
The input record is processed and an
error message is written in the log
file.
Output filename must be different
than the upload filename
The same name is used for the output
and upload files located in the same
directory.
The message is displayed on the
screen and the program ends.
Record number <value>: Invalid
line length; record not processed.
A single-line format input record length
can not be more or less than 834
characters.
It skips the record and continues
processing and an error message is
written in the log file.
The processing option <entered
value> should only be entered
once.
Only one occurrence of each
processing option is allowed.
The message is displayed on the
screen and the program ends.
You have too many applications
open. Close any unnecessary
applications that are open.
The system does not have enough
memory to run the MSG/MCE
application.
The message is displayed on the
screen and the program ends.
4.20 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Log files
The software generates a log file for every batch run and saves it
where the product was installed. Unless specified otherwise, this
directory is: C:\Program Files\CMS\CMSG MCE Software.
By default, the log file is named log.txt, and contains the following
information:
◆
A title line with the name and version number of the product
◆
Input filename
◆
Output filename (if specified)
◆
Upload filename (if specified)
◆
Run start time
◆
Patient ID: <value> followed by error
This line is repeated for however error messages occur for the
same patient record.
◆
Run end time
An example log file is shown in figure 4–2. In this illustration, no
upload filename was specified.
MS Grouper with Medicare Code Editor v27.0
Input file: test.in
Output file: test.out
Upload file:
Start Time: 10/26/09 10:15:34
Patient ID "Record 1": Birth date is invalid
Patient ID "Record 15": Discharge date is invalid
End Time: 10/26/09 10:15:34
Figure 4–2. Sample log file
October 2009
Batch processing 4.21
Log files
07/17/09
Preliminary
The log file can be viewed on your computer screen or printed as
hard copy. The file can also be renamed if you want to save it since
the log file produced in a batch run overwrites the previous one.
Viewing the file
❑
To display the contents of the log file on your screen:
At the system prompt in the directory where the log file was
created, enter:
type <filename> | more
Printing the file
❑
To print the contents of the log file:
At the system prompt in the directory where the log file was
created, enter:
print <filename>
Renaming the file
❑
To rename a log file:
At the system prompt in the directory where the file was created, enter:
rename <old filename> <new filename>
4.22 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Appendix A
Current MDCs and DRGs
A
07/17/09
Contents
Preliminary
Current MDCs and DRGs A.3
A.2 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Appendix A
Current MDCs and DRGs
T
ABLE A–1 LISTS the Major Diagnostic Categories (MDCs) for
version 27.0 of the Medicare Severity (MS) grouper. Table A–2 lists
the Diagnosis Related Groups (DRGs) for version 27.0 of the grouper
and their CMS-designated cost weights. The DRG cost weight is
shown on the software output report (see page 3.14).
Table A–1. List of MDCs(sheet 1 of 2)
MDC
Description
01
Diseases & Disorders of the Nervous System
02
Diseases & Disorders of the Eye
03
Diseases & Disorders of the Ear, Nose, Mouth & Throat
04
Diseases & Disorders of the Respiratory System
05
Diseases & Disorders of the Circulatory System
06
Diseases & Disorders of the Digestive System
07
Diseases & Disorders of the Hepatobiliary System & Pancreas
08
Diseases & Disorders of the Musculoskeletal System & Conn Tissue
09
Diseases & Disorders of the Skin, Subcutaneous Tissue & Breast
10
Endocrine, Nutritional & Metabolic Diseases & Disorders
11
Diseases & Disorders of the Kidney & Urinary Tract
12
Diseases & Disorders of the Male Reproductive System
13
Diseases & Disorders of the Female Reproductive System
14
Pregnancy, Childbirth & the Puerperium
October 2009
Current MDCs and DRGs A.3
07/17/09
Preliminary
Table A–1. List of MDCs(sheet 2 of 2)
MDC
Description
15
Newborns & Other Neonates With Condtn Orig In Perinatal Period
16
Diseases & Disorders of Blood, Blood Forming Organs, Immunolog Disord
17
Myeloproliferative Diseases & Disorders, Poorly Differentiated Neoplasm
18
Infectious & Parasitic Diseases, Systemic or Unspecified Sites
19
Mental Diseases & Disorders
20
Alcohol/drug Use & Alcohol/drug Induced Organic Mental Disorders
21
Injuries, Poisonings & Toxic Effects Of Drugs
22
Burns
23
Factors Influencing Hlth Stat & Othr Contacts With Hlth Servcs
24
Multiple Significant Trauma
25
Human Immunodeficiency Virus Infections
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
001,MDC
P,Heart transplant or implant of heart assist system w MCC
24.8548
002,MDC
P,Heart transplant or implant of heart assist system w/o MCC
11.7540
003,MDC
P,ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R.
18.2667
004,MDC
P,Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R.
11.1941
005,MDC
P,Liver transplant w MCC or intestinal transplant
10.1358
006,MDC
P,Liver transplant w/o MCC
4.7569
007,MDC
P,Lung transplant
9.4543
008,MDC
P,Simultaneous pancreas/kidney transplant
5.0615
009,MDC
P,Bone marrow transplant
6.5419
010,MDC
P,Pancreas transplant
4.2752
011,MDC
P,Tracheostomy for face,mouth & neck diagnoses w MCC
4.7341
012,MDC
P,Tracheostomy for face,mouth & neck diagnoses w CC
3.0306
013,MDC
P,Tracheostomy for face,mouth & neck diagnoses w/o CC/MCC
1.8643
020,MDC 01P,Intracranial vascular procedures w PDX hemorrhage w MCC
8.4392
021,MDC 01P,Intracranial vascular procedures w PDX hemorrhage w CC
6.2068
022,MDC 01P,Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC
4.3765
023,MDC 01P,Cranio w major dev impl/acute complex CNS PDX w MCC or chemo implant
4.9401
024,MDC 01P,Cranio w major dev impl/acute complex CNS PDX w/o MCC
3.2566
025,MDC 01P,Craniotomy & endovascular intracranial procedures w MCC
4.8236
A.4 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
026,MDC 01P,Craniotomy & endovascular intracranial procedures w CC
2.9421
027,MDC 01P,Craniotomy & endovascular intracranial procedures w/o CC/MCC
2.0902
028,MDC 01P,Spinal procedures w MCC
5.1090
029,MDC 01P,Spinal procedures w CC or spinal neurostimulators
2.7768
030,MDC 01P,Spinal procedures w/o CC/MCC
1.6019
031,MDC 01P,Ventricular shunt procedures w MCC
4.5341
032,MDC 01P,Ventricular shunt procedures w CC
1.9186
033,MDC 01P,Ventricular shunt procedures w/o CC/MCC
1.3331
034,MDC 01P,Carotid artery stent procedure w MCC
3.1900
035,MDC 01P,Carotid artery stent procedure w CC
2.0165
036,MDC 01P,Carotid artery stent procedure w/o CC/MCC
1.5744
037,MDC 01P,Extracranial procedures w MCC
2.9190
038,MDC 01P,Extracranial procedures w CC
1.4783
039,MDC 01P,Extracranial procedures w/o CC/MCC
1.0033
040,MDC 01P,Periph/cranial nerve & other nerv syst proc w MCC
3.9518
041,MDC 01P,Periph/cranial nerve & other nerv syst proc w CC or periph neurostim
2.1249
042,MDC 01P,Periph/cranial nerve & other nerv syst proc w/o CC/MCC
1.6448
052,MDC 01M,Spinal disorders & injuries w CC/MCC
1.4836
053,MDC 01M,Spinal disorders & injuries w/o CC/MCC
0.8382
054,MDC 01M,Nervous system neoplasms w MCC
1.5637
055,MDC 01M,Nervous system neoplasms w/o MCC
1.0613
056,MDC 01M,Degenerative nervous system disorders w MCC
1.6952
057,MDC 01M,Degenerative nervous system disorders w/o MCC
0.9028
058,MDC 01M,Multiple sclerosis & cerebellar ataxia w MCC
1.5512
059,MDC 01M,Multiple sclerosis & cerebellar ataxia w CC
0.9581
060,MDC 01M,Multiple sclerosis & cerebellar ataxia w/o CC/MCC
0.7083
061,MDC 01M,Acute ischemic stroke w use of thrombolytic agent w MCC
2.9168
062,MDC 01M,Acute ischemic stroke w use of thrombolytic agent w CC
1.9290
063,MDC 01M,Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC
1.5187
064,MDC 01M,Intracranial hemorrhage or cerebral infarction w MCC
1.8258
065,MDC 01M,Intracranial hemorrhage or cerebral infarction w CC
1.1580
066,MDC 01M,Intracranial hemorrhage or cerebral infarction w/o CC/MCC
0.8223
067,MDC 01M,Nonspecific cva & precerebral occlusion w/o infarct w MCC
1.3335
068,MDC 01M,Nonspecific cva & precerebral occlusion w/o infarct w/o MCC
0.8593
October 2009
Current MDCs and DRGs A.5
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
069,MDC 01M,Transient ischemia
0.7289
070,MDC 01M,Nonspecific cerebrovascular disorders w MCC
1.7919
071,MDC 01M,Nonspecific cerebrovascular disorders w CC
1.1027
072,MDC 01M,Nonspecific cerebrovascular disorders w/o CC/MCC
0.7616
073,MDC 01M,Cranial & peripheral nerve disorders w MCC
1.2939
074,MDC 01M,Cranial & peripheral nerve disorders w/o MCC
0.8380
075,MDC 01M,Viral meningitis w CC/MCC
1.6670
076,MDC 01M,Viral meningitis w/o CC/MCC
0.8336
077,MDC 01M,Hypertensive encephalopathy w MCC
1.6245
078,MDC 01M,Hypertensive encephalopathy w CC
0.9822
079,MDC 01M,Hypertensive encephalopathy w/o CC/MCC
0.7359
080,MDC 01M,Nontraumatic stupor & coma w MCC
1.1461
081,MDC 01M,Nontraumatic stupor & coma w/o MCC
0.7113
082,MDC 01M,Traumatic stupor & coma, coma >1 hr w MCC
2.0130
083,MDC 01M,Traumatic stupor & coma, coma >1 hr w CC
1.3031
084,MDC 01M,Traumatic stupor & coma, coma >1 hr w/o CC/MCC
0.8532
085,MDC 01M,Traumatic stupor & coma, coma <1 hr w MCC
2.0572
086,MDC 01M,Traumatic stupor & coma, coma <1 hr w CC
1.2098
087,MDC 01M,Traumatic stupor & coma, coma <1 hr w/o CC/MCC
0.7815
088,MDC 01M,Concussion w MCC
1.4741
089,MDC 01M,Concussion w CC
0.9298
090,MDC 01M,Concussion w/o CC/MCC
0.6818
091,MDC 01M,Other disorders of nervous system w MCC
1.5465
092,MDC 01M,Other disorders of nervous system w CC
0.9167
093,MDC 01M,Other disorders of nervous system w/o CC/MCC
0.6691
094,MDC 01M,Bacterial & tuberculous infections of nervous system w MCC
3.4161
095,MDC 01M,Bacterial & tuberculous infections of nervous system w CC
2.2416
096,MDC 01M,Bacterial & tuberculous infections of nervous system w/o CC/MCC
1.7927
097,MDC 01M,Non-bacterial infect of nervous sys exc viral meningitis w MCC
3.0233
098,MDC 01M,Non-bacterial infect of nervous sys exc viral meningitis w CC
1.7985
099,MDC 01M,Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC
1.2084
100,MDC 01M,Seizures w MCC
1.4778
101,MDC 01M,Seizures w/o MCC
0.7577
102,MDC 01M,Headaches w MCC
0.9772
A.6 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
103,MDC 01M,Headaches w/o MCC
0.6355
113,MDC 02P,Orbital procedures w CC/MCC
1.7702
114,MDC 02P,Orbital procedures w/o CC/MCC
0.8825
115,MDC 02P,Extraocular procedures except orbit
1.1589
116,MDC 02P,Intraocular procedures w CC/MCC
1.1418
117,MDC 02P,Intraocular procedures w/o CC/MCC
0.6914
121,MDC 02M,Acute major eye infections w CC/MCC
1.0006
122,MDC 02M,Acute major eye infections w/o CC/MCC
0.6713
123,MDC 02M,Neurological eye disorders
0.7153
124,MDC 02M,Other disorders of the eye w MCC
1.1843
125,MDC 02M,Other disorders of the eye w/o MCC
0.6627
129,MDC 03P,Major head & neck procedures w CC/MCC or major device
2.0661
130,MDC 03P,Major head & neck procedures w/o CC/MCC
1.2054
131,MDC 03P,Cranial/facial procedures w CC/MCC
2.0146
132,MDC 03P,Cranial/facial procedures w/o CC/MCC
1.1355
133,MDC 03P,Other ear, nose, mouth & throat O.R. procedures w CC/MCC
1.5884
134,MDC 03P,Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC
0.8166
135,MDC 03P,Sinus & mastoid procedures w CC/MCC
1.8520
136,MDC 03P,Sinus & mastoid procedures w/o CC/MCC
0.9015
137,MDC 03P,Mouth procedures w CC/MCC
1.4004
138,MDC 03P,Mouth procedures w/o CC/MCC
0.7458
139,MDC 03P,Salivary gland procedures
0.8080
146,MDC 03M,Ear, nose, mouth & throat malignancy w MCC
2.1291
147,MDC 03M,Ear, nose, mouth & throat malignancy w CC
1.2345
148,MDC 03M,Ear, nose, mouth & throat malignancy w/o CC/MCC
0.6995
149,MDC 03M,Dysequilibrium
0.6293
150,MDC 03M,Epistaxis w MCC
1.3363
151,MDC 03M,Epistaxis w/o MCC
0.6194
152,MDC 03M,Otitis media & URI w MCC
0.9396
153,MDC 03M,Otitis media & URI w/o MCC
0.6084
154,MDC 03M,Other ear, nose, mouth & throat diagnoses w MCC
1.3872
155,MDC 03M,Other ear, nose, mouth & throat diagnoses w CC
0.8823
156,MDC 03M,Other ear, nose, mouth & throat diagnoses w/o CC/MCC
0.6201
157,MDC 03M,Dental & Oral Diseases w MCC
1.4763
October 2009
Current MDCs and DRGs A.7
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
158,MDC 03M,Dental & Oral Diseases w CC
0.9235
159,MDC 03M,Dental & Oral Diseases w/o CC/MCC
0.5949
163,MDC 04P,Major chest procedures w MCC
4.9549
164,MDC 04P,Major chest procedures w CC
2.5164
165,MDC 04P,Major chest procedures w/o CC/MCC
1.7662
166,MDC 04P,Other resp system O.R. procedures w MCC
3.7227
167,MDC 04P,Other resp system O.R. procedures w CC
2.0068
168,MDC 04P,Other resp system O.R. procedures w/o CC/MCC
1.3026
175,MDC 04M,Pulmonary embolism w MCC
1.6121
176,MDC 04M,Pulmonary embolism w/o MCC
1.0685
177,MDC 04M,Respiratory infections & inflammations w MCC
2.0483
178,MDC 04M,Respiratory infections & inflammations w CC
1.4860
179,MDC 04M,Respiratory infections & inflammations w/o CC/MCC
1.0088
180,MDC 04M,Respiratory neoplasms w MCC
1.7263
181,MDC 04M,Respiratory neoplasms w CC
1.2062
182,MDC 04M,Respiratory neoplasms w/o CC/MCC
0.8159
183,MDC 04M,Major chest trauma w MCC
1.4432
184,MDC 04M,Major chest trauma w CC
0.9483
185,MDC 04M,Major chest trauma w/o CC/MCC
0.6665
186,MDC 04M,Pleural effusion w MCC
1.5917
187,MDC 04M,Pleural effusion w CC
1.0620
188,MDC 04M,Pleural effusion w/o CC/MCC
0.7612
189,MDC 04M,Pulmonary edema & respiratory failure
1.3455
190,MDC 04M,Chronic obstructive pulmonary disease w MCC
1.2076
191,MDC 04M,Chronic obstructive pulmonary disease w CC
0.9622
192,MDC 04M,Chronic obstructive pulmonary disease w/o CC/MCC
0.7175
193,MDC 04M,Simple pneumonia & pleurisy w MCC
1.4378
194,MDC 04M,Simple pneumonia & pleurisy w CC
0.9976
195,MDC 04M,Simple pneumonia & pleurisy w/o CC/MCC
0.7095
196,MDC 04M,Interstitial lung disease w MCC
1.5396
197,MDC 04M,Interstitial lung disease w CC
1.0647
198,MDC 04M,Interstitial lung disease w/o CC/MCC
0.8137
199,MDC 04M,Pneumothorax w MCC
1.8266
200,MDC 04M,Pneumothorax w CC
0.9745
A.8 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
201,MDC 04M,Pneumothorax w/o CC/MCC
0.7144
202,MDC 04M,Bronchitis & asthma w CC/MCC
0.8374
203,MDC 04M,Bronchitis & asthma w/o CC/MCC
0.6055
204,MDC 04M,Respiratory signs & symptoms
0.6472
205,MDC 04M,Other respiratory system diagnoses w MCC
1.2566
206,MDC 04M,Other respiratory system diagnoses w/o MCC
0.7294
207,MDC 04M,Respiratory system diagnosis w ventilator support 96+ hours
5.1780
208,MDC 04M,Respiratory system diagnosis w ventilator support <96 hours
2.2358
215,MDC 05P,Other heart assist system implant
12.8304
216,MDC 05P,Cardiac valve & oth maj cardiothoracic proc w card cath w MCC
10.1967
217,MDC 05P,Cardiac valve & oth maj cardiothoracic proc w card cath w CC
6.5932
218,MDC 05P,Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC
5.2809
219,MDC 05P,Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC
7.9336
220,MDC 05P,Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC
5.1767
221,MDC 05P,Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC
4.3926
222,MDC 05P,Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC
8.4829
223,MDC 05P,Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC
6.2229
224,MDC 05P,Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC
7.5477
225,MDC 05P,Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC
5.8321
226,MDC 05P,Cardiac defibrillator implant w/o cardiac cath w MCC
6.5457
227,MDC 05P,Cardiac defibrillator implant w/o cardiac cath w/o MCC
5.0519
228,MDC 05P,Other cardiothoracic procedures w MCC
7.5401
229,MDC 05P,Other cardiothoracic procedures w CC
4.8428
230,MDC 05P,Other cardiothoracic procedures w/o CC/MCC
3.7989
231,MDC 05P,Coronary bypass w PTCA w MCC
7.6784
232,MDC 05P,Coronary bypass w PTCA w/o MCC
5.5589
233,MDC 05P,Coronary bypass w cardiac cath w MCC
6.9240
234,MDC 05P,Coronary bypass w cardiac cath w/o MCC
4.6212
235,MDC 05P,Coronary bypass w/o cardiac cath w MCC
5.6898
236,MDC 05P,Coronary bypass w/o cardiac cath w/o MCC
3.6128
237,MDC 05P,Major cardiovasc procedures w MCC or thoracic aortic aneurysm repair
5.0355
238,MDC 05P,Major cardiovasc procedures w/o MCC
2.9366
239,MDC 05P,Amputation for circ sys disorders exc upper limb & toe w MCC
4.7275
240,MDC 05P,Amputation for circ sys disorders exc upper limb & toe w CC
2.5377
October 2009
Current MDCs and DRGs A.9
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
241,MDC 05P,Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC
1.4922
242,MDC 05P,Permanent cardiac pacemaker implant w MCC
3.5878
243,MDC 05P,Permanent cardiac pacemaker implant w CC
2.5737
244,MDC 05P,Permanent cardiac pacemaker implant w/o CC/MCC
1.9888
245,MDC 05P,AICD generator procedures
4.0534
246,MDC 05P,Perc cardiovasc proc w drug-eluting stent w MCC or 4+ vessels/stents
3.0955
247,MDC 05P,Perc cardiovasc proc w drug-eluting stent w/o MCC
1.9121
248,MDC 05P,Perc cardiovasc proc w non-drug-eluting stent w MCC or 4+ ves/stents
2.8419
249,MDC 05P,Perc cardiovasc proc w non-drug-eluting stent w/o MCC
1.6840
250,MDC 05P,Perc cardiovasc proc w/o coronary artery stent w MCC
2.7546
251,MDC 05P,Perc cardiovasc proc w/o coronary artery stent w/o MCC
1.6455
252,MDC 05P,Other vascular procedures w MCC
2.9443
253,MDC 05P,Other vascular procedures w CC
2.2817
254,MDC 05P,Other vascular procedures w/o CC/MCC
1.5713
255,MDC 05P,Upper limb & toe amputation for circ system disorders w MCC
2.5388
256,MDC 05P,Upper limb & toe amputation for circ system disorders w CC
1.5518
257,MDC 05P,Upper limb & toe amputation for circ system disorders w/o CC/MCC
0.9529
258,MDC 05P,Cardiac pacemaker device replacement w MCC
2.8006
259,MDC 05P,Cardiac pacemaker device replacement w/o MCC
1.7191
260,MDC 05P,Cardiac pacemaker revision except device replacement w MCC
3.2956
261,MDC 05P,Cardiac pacemaker revision except device replacement w CC
1.4677
262,MDC 05P,Cardiac pacemaker revision except device replacement w/o CC/MCC
1.0412
263,MDC 05P,Vein ligation & stripping
1.6163
264,MDC 05P,Other circulatory system O.R. procedures
2.5087
265,MDC 05P,AICD lead procedures
2.2407
280,MDC 05M,Acute myocardial infarction, discharged alive w MCC
1.8313
281,MDC 05M,Acute myocardial infarction, discharged alive w CC
1.1620
282,MDC 05M,Acute myocardial infarction, discharged alive w/o CC/MCC
0.8177
283,MDC 05M,Acute myocardial infarction, expired w MCC
1.6717
284,MDC 05M,Acute myocardial infarction, expired w CC
0.8024
285,MDC 05M,Acute myocardial infarction, expired w/o CC/MCC
0.5602
286,MDC 05M,Circulatory disorders except AMI, w card cath w MCC
1.9634
287,MDC 05M,Circulatory disorders except AMI, w card cath w/o MCC
1.0321
288,MDC 05M,Acute & subacute endocarditis w MCC
3.0888
A.10 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
289,MDC 05M,Acute & subacute endocarditis w CC
1.8496
290,MDC 05M,Acute & subacute endocarditis w/o CC/MCC
1.2313
291,MDC 05M,Heart failure & shock w MCC
1.4609
292,MDC 05M,Heart failure & shock w CC
0.9740
293,MDC 05M,Heart failure & shock w/o CC/MCC
0.6940
294,MDC 05M,Deep vein thrombophlebitis w CC/MCC
1.0104
295,MDC 05M,Deep vein thrombophlebitis w/o CC/MCC
0.6504
296,MDC 05M,Cardiac arrest, unexplained w MCC
1.1665
297,MDC 05M,Cardiac arrest, unexplained w CC
0.6704
298,MDC 05M,Cardiac arrest, unexplained w/o CC/MCC
0.4469
299,MDC 05M,Peripheral vascular disorders w MCC
1.4045
300,MDC 05M,Peripheral vascular disorders w CC
0.9378
301,MDC 05M,Peripheral vascular disorders w/o CC/MCC
0.6522
302,MDC 05M,Atherosclerosis w MCC
0.9999
303,MDC 05M,Atherosclerosis w/o MCC
0.5681
304,MDC 05M,Hypertension w MCC
1.0242
305,MDC 05M,Hypertension w/o MCC
0.5959
306,MDC 05M,Cardiac congenital & valvular disorders w MCC
1.3076
307,MDC 05M,Cardiac congenital & valvular disorders w/o MCC
0.7624
308,MDC 05M,Cardiac arrhythmia & conduction disorders w MCC
1.2188
309,MDC 05M,Cardiac arrhythmia & conduction disorders w CC
0.8207
310,MDC 05M,Cardiac arrhythmia & conduction disorders w/o CC/MCC
0.5710
311,MDC 05M,Angina pectoris
0.5128
312,MDC 05M,Syncope & collapse
0.7215
313,MDC 05M,Chest pain
0.5404
314,MDC 05M,Other circulatory system diagnoses w MCC
1.7589
315,MDC 05M,Other circulatory system diagnoses w CC
0.9598
316,MDC 05M,Other circulatory system diagnoses w/o CC/MCC
0.6211
326,MDC 06P,Stomach, esophageal & duodenal proc w MCC
5.6845
327,MDC 06P,Stomach, esophageal & duodenal proc w CC
2.7062
328,MDC 06P,Stomach, esophageal & duodenal proc w/o CC/MCC
1.3950
329,MDC 06P,Major small & large bowel procedures w MCC
5.1396
330,MDC 06P,Major small & large bowel procedures w CC
2.4981
331,MDC 06P,Major small & large bowel procedures w/o CC/MCC
1.5952
October 2009
Current MDCs and DRGs A.11
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
332,MDC 06P,Rectal resection w MCC
4.7762
333,MDC 06P,Rectal resection w CC
2.4150
334,MDC 06P,Rectal resection w/o CC/MCC
1.6208
335,MDC 06P,Peritoneal adhesiolysis w MCC
4.1422
336,MDC 06P,Peritoneal adhesiolysis w CC
2.2458
337,MDC 06P,Peritoneal adhesiolysis w/o CC/MCC
1.4441
338,MDC 06P,Appendectomy w complicated principal diag w MCC
3.0677
339,MDC 06P,Appendectomy w complicated principal diag w CC
1.7979
340,MDC 06P,Appendectomy w complicated principal diag w/o CC/MCC
1.2197
341,MDC 06P,Appendectomy w/o complicated principal diag w MCC
2.2109
342,MDC 06P,Appendectomy w/o complicated principal diag w CC
1.3112
343,MDC 06P,Appendectomy w/o complicated principal diag w/o CC/MCC
0.9360
344,MDC 06P,Minor small & large bowel procedures w MCC
3.0345
345,MDC 06P,Minor small & large bowel procedures w CC
1.6179
346,MDC 06P,Minor small & large bowel procedures w/o CC/MCC
1.1755
347,MDC 06P,Anal & stomal procedures w MCC
2.2657
348,MDC 06P,Anal & stomal procedures w CC
1.3237
349,MDC 06P,Anal & stomal procedures w/o CC/MCC
0.7665
350,MDC 06P,Inguinal & femoral hernia procedures w MCC
2.2798
351,MDC 06P,Inguinal & femoral hernia procedures w CC
1.2628
352,MDC 06P,Inguinal & femoral hernia procedures w/o CC/MCC
0.8210
353,MDC 06P,Hernia procedures except inguinal & femoral w MCC
2.5349
354,MDC 06P,Hernia procedures except inguinal & femoral w CC
1.4337
355,MDC 06P,Hernia procedures except inguinal & femoral w/o CC/MCC
0.9878
356,MDC 06P,Other digestive system O.R. procedures w MCC
3.9597
357,MDC 06P,Other digestive system O.R. procedures w CC
2.1160
358,MDC 06P,Other digestive system O.R. procedures w/o CC/MCC
1.3008
368,MDC 06M,Major esophageal disorders w MCC
1.6584
369,MDC 06M,Major esophageal disorders w CC
1.0480
370,MDC 06M,Major esophageal disorders w/o CC/MCC
0.7501
371,MDC 06M,Major gastrointestinal disorders & peritoneal infections w MCC
1.9214
372,MDC 06M,Major gastrointestinal disorders & peritoneal infections w CC
1.2865
373,MDC 06M,Major gastrointestinal disorders & peritoneal infections w/o CC/MCC
0.8619
374,MDC 06M,Digestive malignancy w MCC
2.0149
A.12 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
375,MDC 06M,Digestive malignancy w CC
1.2631
376,MDC 06M,Digestive malignancy w/o CC/MCC
0.8883
377,MDC 06M,G.I. hemorrhage w MCC
1.6149
378,MDC 06M,G.I. hemorrhage w CC
0.9873
379,MDC 06M,G.I. hemorrhage w/o CC/MCC
0.7179
380,MDC 06M,Complicated peptic ulcer w MCC
1.7333
381,MDC 06M,Complicated peptic ulcer w CC
1.0853
382,MDC 06M,Complicated peptic ulcer w/o CC/MCC
0.7785
383,MDC 06M,Uncomplicated peptic ulcer w MCC
1.2399
384,MDC 06M,Uncomplicated peptic ulcer w/o MCC
0.8146
385,MDC 06M,Inflammatory bowel disease w MCC
1.7089
386,MDC 06M,Inflammatory bowel disease w CC
1.0423
387,MDC 06M,Inflammatory bowel disease w/o CC/MCC
0.7871
388,MDC 06M,G.I. obstruction w MCC
1.5060
389,MDC 06M,G.I. obstruction w CC
0.9268
390,MDC 06M,G.I. obstruction w/o CC/MCC
0.6341
391,MDC 06M,Esophagitis, gastroent & misc digest disorders w MCC
1.0958
392,MDC 06M,Esophagitis, gastroent & misc digest disorders w/o MCC
0.6921
393,MDC 06M,Other digestive system diagnoses w MCC
1.5632
394,MDC 06M,Other digestive system diagnoses w CC
0.9572
395,MDC 06M,Other digestive system diagnoses w/o CC/MCC
0.6666
405,MDC 07P,Pancreas, liver & shunt procedures w MCC
5.5911
406,MDC 07P,Pancreas, liver & shunt procedures w CC
2.6729
407,MDC 07P,Pancreas, liver & shunt procedures w/o CC/MCC
1.8068
408,MDC 07P,Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC
4.0844
409,MDC 07P,Biliary tract proc except only cholecyst w or w/o c.d.e. w CC
2.3103
410,MDC 07P,Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC
1.6134
411,MDC 07P,Cholecystectomy w c.d.e. w MCC
3.9655
412,MDC 07P,Cholecystectomy w c.d.e. w CC
2.3982
413,MDC 07P,Cholecystectomy w c.d.e. w/o CC/MCC
1.6222
414,MDC 07P,Cholecystectomy except by laparoscope w/o c.d.e. w MCC
3.6023
415,MDC 07P,Cholecystectomy except by laparoscope w/o c.d.e. w CC
1.9824
416,MDC 07P,Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC
1.2904
417,MDC 07P,Laparoscopic cholecystectomy w/o c.d.e. w MCC
2.4050
October 2009
Current MDCs and DRGs A.13
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
418,MDC 07P,Laparoscopic cholecystectomy w/o c.d.e. w CC
1.6354
419,MDC 07P,Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC
1.1334
420,MDC 07P,Hepatobiliary diagnostic procedures w MCC
4.1182
421,MDC 07P,Hepatobiliary diagnostic procedures w CC
1.6987
422,MDC 07P,Hepatobiliary diagnostic procedures w/o CC/MCC
1.1791
423,MDC 07P,Other hepatobiliary or pancreas O.R. procedures w MCC
4.2255
424,MDC 07P,Other hepatobiliary or pancreas O.R. procedures w CC
2.2105
425,MDC 07P,Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC
1.4477
432,MDC 07M,Cirrhosis & alcoholic hepatitis w MCC
1.6369
433,MDC 07M,Cirrhosis & alcoholic hepatitis w CC
0.9076
434,MDC 07M,Cirrhosis & alcoholic hepatitis w/o CC/MCC
0.6489
435,MDC 07M,Malignancy of hepatobiliary system or pancreas w MCC
1.7293
436,MDC 07M,Malignancy of hepatobiliary system or pancreas w CC
1.1831
437,MDC 07M,Malignancy of hepatobiliary system or pancreas w/o CC/MCC
0.8780
438,MDC 07M,Disorders of pancreas except malignancy w MCC
1.6993
439,MDC 07M,Disorders of pancreas except malignancy w CC
0.9960
440,MDC 07M,Disorders of pancreas except malignancy w/o CC/MCC
0.6865
441,MDC 07M,Disorders of liver except malig,cirr,alc hepa w MCC
1.7290
442,MDC 07M,Disorders of liver except malig,cirr,alc hepa w CC
0.9407
443,MDC 07M,Disorders of liver except malig,cirr,alc hepa w/o CC/MCC
0.6631
444,MDC 07M,Disorders of the biliary tract w MCC
1.5055
445,MDC 07M,Disorders of the biliary tract w CC
1.0386
446,MDC 07M,Disorders of the biliary tract w/o CC/MCC
0.7239
453,MDC 08P,Combined anterior/posterior spinal fusion w MCC
10.0108
454,MDC 08P,Combined anterior/posterior spinal fusion w CC
6.9533
455,MDC 08P,Combined anterior/posterior spinal fusion w/o CC/MCC
5.0197
456,MDC 08P,Spinal fus exc cerv w spinal curv/malig/infec or 9+ fus w MCC
8.7412
457,MDC 08P,Spinal fus exc cerv w spinal curv/malig/infec or 9+ fus w CC
5.9617
458,MDC 08P,Spinal fus exc cerv w spinal curv/malig/infec or 9+ fus w/o CC/MCC
4.8966
459,MDC 08P,Spinal fusion except cervical w MCC
6.1506
460,MDC 08P,Spinal fusion except cervical w/o MCC
3.7097
461,MDC 08P,Bilateral or multiple major joint procs of lower extremity w MCC
4.5614
462,MDC 08P,Bilateral or multiple major joint procs of lower extremity w/o MCC
3.2056
463,MDC 08P,Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w MCC
5.3025
A.14 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
464,MDC 08P,Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w CC
2.8384
465,MDC 08P,Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC
1.7896
466,MDC 08P,Revision of hip or knee replacement w MCC
4.6698
467,MDC 08P,Revision of hip or knee replacement w CC
3.1207
468,MDC 08P,Revision of hip or knee replacement w/o CC/MCC
2.5167
469,MDC 08P,Major joint replacement or reattachment of lower extremity w MCC
3.3282
470,MDC 08P,Major joint replacement or reattachment of lower extremity w/o MCC
2.0613
471,MDC 08P,Cervical spinal fusion w MCC
4.6182
472,MDC 08P,Cervical spinal fusion w CC
2.7547
473,MDC 08P,Cervical spinal fusion w/o CC/MCC
2.0033
474,MDC 08P,Amputation for musculoskeletal sys & conn tissue dis w MCC
3.5040
475,MDC 08P,Amputation for musculoskeletal sys & conn tissue dis w CC
1.9230
476,MDC 08P,Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC
1.0650
477,MDC 08P,Biopsies of musculoskeletal system & connective tissue w MCC
3.1343
478,MDC 08P,Biopsies of musculoskeletal system & connective tissue w CC
2.1321
479,MDC 08P,Biopsies of musculoskeletal system & connective tissue w/o CC/MCC
1.5121
480,MDC 08P,Hip & femur procedures except major joint w MCC
2.8752
481,MDC 08P,Hip & femur procedures except major joint w CC
1.8373
482,MDC 08P,Hip & femur procedures except major joint w/o CC/MCC
1.5071
483,MDC 08P,Major joint & limb reattachment proc of upper extremity w CC/MCC
2.3024
484,MDC 08P,Major joint & limb reattachment proc of upper extremity w/o CC/MCC
1.8358
485,MDC 08P,Knee procedures w pdx of infection w MCC
3.0871
486,MDC 08P,Knee procedures w pdx of infection w CC
2.0558
487,MDC 08P,Knee procedures w pdx of infection w/o CC/MCC
1.4338
488,MDC 08P,Knee procedures w/o pdx of infection w CC/MCC
1.6774
489,MDC 08P,Knee procedures w/o pdx of infection w/o CC/MCC
1.1830
490,MDC 08P,Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim
1.7718
491,MDC 08P,Back & neck proc exc spinal fusion w/o CC/MCC
0.9522
492,MDC 08P,Lower extrem & humer proc except hip,foot,femur w MCC
2.8500
493,MDC 08P,Lower extrem & humer proc except hip,foot,femur w CC
1.7806
494,MDC 08P,Lower extrem & humer proc except hip,foot,femur w/o CC/MCC
1.2619
495,MDC 08P,Local excision & removal int fix devices exc hip & femur w MCC
2.8743
496,MDC 08P,Local excision & removal int fix devices exc hip & femur w CC
1.6254
497,MDC 08P,Local excision & removal int fix devices exc hip & femur w/o CC/MCC
1.0344
October 2009
Current MDCs and DRGs A.15
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
498,MDC 08P,Local excision & removal int fix devices of hip & femur w CC/MCC
1.9228
499,MDC 08P,Local excision & removal int fix devices of hip & femur w/o CC/MCC
0.8975
500,MDC 08P,Soft tissue procedures w MCC
3.0244
501,MDC 08P,Soft tissue procedures w CC
1.5169
502,MDC 08P,Soft tissue procedures w/o CC/MCC
0.9834
503,MDC 08P,Foot procedures w MCC
2.1835
504,MDC 08P,Foot procedures w CC
1.5082
505,MDC 08P,Foot procedures w/o CC/MCC
1.0282
506,MDC 08P,Major thumb or joint procedures
1.1381
507,MDC 08P,Major shoulder or elbow joint procedures w CC/MCC
1.8188
508,MDC 08P,Major shoulder or elbow joint procedures w/o CC/MCC
1.2568
509,MDC 08P,Arthroscopy
1.2065
510,MDC 08P,Shoulder,elbow or forearm proc,exc major joint proc w MCC
2.1482
511,MDC 08P,Shoulder,elbow or forearm proc,exc major joint proc w CC
1.3747
512,MDC 08P,Shoulder,elbow or forearm proc,exc major joint proc w/o CC/MCC
1.0033
513,MDC 08P,Hand or wrist proc, except major thumb or joint proc w CC/MCC
1.2327
514,MDC 08P,Hand or wrist proc, except major thumb or joint proc w/o CC/MCC
0.7712
515,MDC 08P,Other musculoskelet sys & conn tiss O.R. proc w MCC
3.0414
516,MDC 08P,Other musculoskelet sys & conn tiss O.R. proc w CC
1.8355
517,MDC 08P,Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC
1.3640
533,MDC 08M,Fractures of femur w MCC
1.5632
534,MDC 08M,Fractures of femur w/o MCC
0.7386
535,MDC 08M,Fractures of hip & pelvis w MCC
1.2914
536,MDC 08M,Fractures of hip & pelvis w/o MCC
0.7127
537,MDC 08M,Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC
0.8831
538,MDC 08M,Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC
0.5863
539,MDC 08M,Osteomyelitis w MCC
2.2839
540,MDC 08M,Osteomyelitis w CC
1.3839
541,MDC 08M,Osteomyelitis w/o CC/MCC
0.9422
542,MDC 08M,Pathological fractures & musculoskelet & conn tiss malig w MCC
1.9540
543,MDC 08M,Pathological fractures & musculoskelet & conn tiss malig w CC
1.1211
544,MDC 08M,Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC
0.7717
545,MDC 08M,Connective tissue disorders w MCC
2.2783
546,MDC 08M,Connective tissue disorders w CC
1.0758
A.16 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
547,MDC 08M,Connective tissue disorders w/o CC/MCC
0.7475
548,MDC 08M,Septic arthritis w MCC
1.9281
549,MDC 08M,Septic arthritis w CC
1.1758
550,MDC 08M,Septic arthritis w/o CC/MCC
0.7082
551,MDC 08M,Medical back problems w MCC
1.5442
552,MDC 08M,Medical back problems w/o MCC
0.7937
553,MDC 08M,Bone diseases & arthropathies w MCC
1.1057
554,MDC 08M,Bone diseases & arthropathies w/o MCC
0.6478
555,MDC 08M,Signs & symptoms of musculoskeletal system & conn tissue w MCC
0.9698
556,MDC 08M,Signs & symptoms of musculoskeletal system & conn tissue w/o MCC
0.6027
557,MDC 08M,Tendonitis, myositis & bursitis w MCC
1.4685
558,MDC 08M,Tendonitis, myositis & bursitis w/o MCC
0.8387
559,MDC 08M,Aftercare, musculoskeletal system & connective tissue w MCC
1.7514
560,MDC 08M,Aftercare, musculoskeletal system & connective tissue w CC
0.9852
561,MDC 08M,Aftercare, musculoskeletal system & connective tissue w/o CC/MCC
0.5959
562,MDC 08M,Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC
1.3793
563,MDC 08M,Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC
0.6927
564,MDC 08M,Other musculoskeletal sys & connective tissue diagnoses w MCC
1.5068
565,MDC 08M,Other musculoskeletal sys & connective tissue diagnoses w CC
0.9070
566,MDC 08M,Other musculoskeletal sys & connective tissue diagnoses w/o CC/MCC
0.6498
573,MDC 09P,Skin graft &/or debrid for skn ulcer or cellulitis w MCC
3.5286
574,MDC 09P,Skin graft &/or debrid for skn ulcer or cellulitis w CC
1.9090
575,MDC 09P,Skin graft &/or debrid for skn ulcer or cellulitis w/o CC/MCC
1.1260
576,MDC 09P,Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC
3.3598
577,MDC 09P,Skin graft &/or debrid exc for skin ulcer or cellulitis w CC
1.7235
578,MDC 09P,Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC
0.9925
579,MDC 09P,Other skin, subcut tiss & breast proc w MCC
2.8556
580,MDC 09P,Other skin, subcut tiss & breast proc w CC
1.3997
581,MDC 09P,Other skin, subcut tiss & breast proc w/o CC/MCC
0.8589
582,MDC 09P,Mastectomy for malignancy w CC/MCC
1.0226
583,MDC 09P,Mastectomy for malignancy w/o CC/MCC
0.7889
584,MDC 09P,Breast biopsy, local excision & other breast procedures w CC/MCC
1.4877
585,MDC 09P,Breast biopsy, local excision & other breast procedures w/o CC/MCC
0.8593
592,MDC 09M,Skin ulcers w MCC
1.8499
October 2009
Current MDCs and DRGs A.17
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
593,MDC 09M,Skin ulcers w CC
1.0807
594,MDC 09M,Skin ulcers w/o CC/MCC
0.7523
595,MDC 09M,Major skin disorders w MCC
1.7691
596,MDC 09M,Major skin disorders w/o MCC
0.8285
597,MDC 09M,Malignant breast disorders w MCC
1.6302
598,MDC 09M,Malignant breast disorders w CC
1.0650
599,MDC 09M,Malignant breast disorders w/o CC/MCC
0.6102
600,MDC 09M,Non-malignant breast disorders w CC/MCC
0.9801
601,MDC 09M,Non-malignant breast disorders w/o CC/MCC
0.5941
602,MDC 09M,Cellulitis w MCC
1.4300
603,MDC 09M,Cellulitis w/o MCC
0.8178
604,MDC 09M,Trauma to the skin, subcut tiss & breast w MCC
1.1719
605,MDC 09M,Trauma to the skin, subcut tiss & breast w/o MCC
0.6824
606,MDC 09M,Minor skin disorders w MCC
1.1964
607,MDC 09M,Minor skin disorders w/o MCC
0.6403
614,MDC 10P,Adrenal & pituitary procedures w CC/MCC
2.6525
615,MDC 10P,Adrenal & pituitary procedures w/o CC/MCC
1.3859
616,MDC 10P,Amputat of lower limb for endocrine,nutrit,& metabol dis w MCC
4.8537
617,MDC 10P,Amputat of lower limb for endocrine,nutrit,& metabol dis w CC
2.0316
618,MDC 10P,Amputat of lower limb for endocrine,nutrit,& metabol dis w/o CC/MCC
1.2713
619,MDC 10P,O.R. procedures for obesity w MCC
3.5839
620,MDC 10P,O.R. procedures for obesity w CC
1.8258
621,MDC 10P,O.R. procedures for obesity w/o CC/MCC
1.4500
622,MDC 10P,Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC
4.2285
623,MDC 10P,Skin grafts & wound debrid for endoc, nutrit & metab dis w CC
2.0271
624,MDC 10P,Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC
1.1304
625,MDC 10P,Thyroid, parathyroid & thyroglossal procedures w MCC
2.2380
626,MDC 10P,Thyroid, parathyroid & thyroglossal procedures w CC
1.1339
627,MDC 10P,Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC
0.7545
628,MDC 10P,Other endocrine, nutrit & metab O.R. proc w MCC
3.3978
629,MDC 10P,Other endocrine, nutrit & metab O.R. proc w CC
2.3003
630,MDC 10P,Other endocrine, nutrit & metab O.R. proc w/o CC/MCC
1.4359
637,MDC 10M,Diabetes w MCC
1.3303
638,MDC 10M,Diabetes w CC
0.8263
A.18 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
639,MDC 10M,Diabetes w/o CC/MCC
0.5547
640,MDC 10M,Nutritional & misc metabolic disorders w MCC
1.0896
641,MDC 10M,Nutritional & misc metabolic disorders w/o MCC
0.6843
642,MDC 10M,Inborn errors of metabolism
1.0463
643,MDC 10M,Endocrine disorders w MCC
1.6325
644,MDC 10M,Endocrine disorders w CC
1.0453
645,MDC 10M,Endocrine disorders w/o CC/MCC
0.7187
652,MDC 11P,Kidney transplant
2.9736
653,MDC 11P,Major bladder procedures w MCC
5.8189
654,MDC 11P,Major bladder procedures w CC
2.8942
655,MDC 11P,Major bladder procedures w/o CC/MCC
1.9180
656,MDC 11P,Kidney & ureter procedures for neoplasm w MCC
3.2592
657,MDC 11P,Kidney & ureter procedures for neoplasm w CC
1.8523
658,MDC 11P,Kidney & ureter procedures for neoplasm w/o CC/MCC
1.3668
659,MDC 11P,Kidney & ureter procedures for non-neoplasm w MCC
3.2812
660,MDC 11P,Kidney & ureter procedures for non-neoplasm w CC
1.8136
661,MDC 11P,Kidney & ureter procedures for non-neoplasm w/o CC/MCC
1.2817
662,MDC 11P,Minor bladder procedures w MCC
2.7753
663,MDC 11P,Minor bladder procedures w CC
1.3713
664,MDC 11P,Minor bladder procedures w/o CC/MCC
1.0193
665,MDC 11P,Prostatectomy w MCC
2.8052
666,MDC 11P,Prostatectomy w CC
1.5506
667,MDC 11P,Prostatectomy w/o CC/MCC
0.7615
668,MDC 11P,Transurethral procedures w MCC
2.2481
669,MDC 11P,Transurethral procedures w CC
1.1938
670,MDC 11P,Transurethral procedures w/o CC/MCC
0.7573
671,MDC 11P,Urethral procedures w CC/MCC
1.4698
672,MDC 11P,Urethral procedures w/o CC/MCC
0.7699
673,MDC 11P,Other kidney & urinary tract procedures w MCC
2.9192
674,MDC 11P,Other kidney & urinary tract procedures w CC
2.0576
675,MDC 11P,Other kidney & urinary tract procedures w/o CC/MCC
1.3129
682,MDC 11M,Renal failure w MCC
1.6422
683,MDC 11M,Renal failure w CC
1.0523
684,MDC 11M,Renal failure w/o CC/MCC
0.6746
October 2009
Current MDCs and DRGs A.19
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
685,MDC 11M,Admit for renal dialysis
0.8994
686,MDC 11M,Kidney & urinary tract neoplasms w MCC
1.5362
687,MDC 11M,Kidney & urinary tract neoplasms w CC
1.0260
688,MDC 11M,Kidney & urinary tract neoplasms w/o CC/MCC
0.6852
689,MDC 11M,Kidney & urinary tract infections w MCC
1.2122
690,MDC 11M,Kidney & urinary tract infections w/o MCC
0.7708
691,MDC 11M,Urinary stones w esw lithotripsy w CC/MCC
1.4711
692,MDC 11M,Urinary stones w esw lithotripsy w/o CC/MCC
1.1044
693,MDC 11M,Urinary stones w/o esw lithotripsy w MCC
1.1496
694,MDC 11M,Urinary stones w/o esw lithotripsy w/o MCC
0.6539
695,MDC 11M,Kidney & urinary tract signs & symptoms w MCC
1.2396
696,MDC 11M,Kidney & urinary tract signs & symptoms w/o MCC
0.6453
697,MDC 11M,Urethral stricture
0.8140
698,MDC 11M,Other kidney & urinary tract diagnoses w MCC
1.4877
699,MDC 11M,Other kidney & urinary tract diagnoses w CC
0.9518
700,MDC 11M,Other kidney & urinary tract diagnoses w/o CC/MCC
0.6533
707,MDC 12P,Major male pelvic procedures w CC/MCC
1.6691
708,MDC 12P,Major male pelvic procedures w/o CC/MCC
1.2024
709,MDC 12P,Penis procedures w CC/MCC
1.8350
710,MDC 12P,Penis procedures w/o CC/MCC
1.3227
711,MDC 12P,Testes procedures w CC/MCC
1.7128
712,MDC 12P,Testes procedures w/o CC/MCC
0.7666
713,MDC 12P,Transurethral prostatectomy w CC/MCC
1.1285
714,MDC 12P,Transurethral prostatectomy w/o CC/MCC
0.6364
715,MDC 12P,Other male reproductive system O.R. proc for malignancy w CC/MCC
1.7460
716,MDC 12P,Other male reproductive system O.R. proc for malignancy w/o CC/MCC
1.0053
717,MDC 12P,Other male reproductive system O.R. proc exc malignancy w CC/MCC
1.6782
718,MDC 12P,Other male reproductive system O.R. proc exc malignancy w/o CC/MCC
0.7921
722,MDC 12M,Malignancy, male reproductive system w MCC
1.4962
723,MDC 12M,Malignancy, male reproductive system w CC
0.9732
724,MDC 12M,Malignancy, male reproductive system w/o CC/MCC
0.6288
725,MDC 12M,Benign prostatic hypertrophy w MCC
1.0685
726,MDC 12M,Benign prostatic hypertrophy w/o MCC
0.6979
727,MDC 12M,Inflammation of the male reproductive system w MCC
1.3162
A.20 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
728,MDC 12M,Inflammation of the male reproductive system w/o MCC
0.7331
729,MDC 12M,Other male reproductive system diagnoses w CC/MCC
0.9642
730,MDC 12M,Other male reproductive system diagnoses w/o CC/MCC
0.5786
734,MDC 13P,Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC
2.5091
735,MDC 13P,Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC
1.1370
736,MDC 13P,Uterine & adnexa proc for ovarian or adnexal malignancy w MCC
4.3490
737,MDC 13P,Uterine & adnexa proc for ovarian or adnexal malignancy w CC
1.9651
738,MDC 13P,Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC
1.1766
739,MDC 13P,Uterine,adnexa proc for non-ovarian/adnexal malig w MCC
3.0553
740,MDC 13P,Uterine,adnexa proc for non-ovarian/adnexal malig w CC
1.5028
741,MDC 13P,Uterine,adnexa proc for non-ovarian/adnexal malig w/o CC/MCC
1.0568
742,MDC 13P,Uterine & adnexa proc for non-malignancy w CC/MCC
1.3481
743,MDC 13P,Uterine & adnexa proc for non-malignancy w/o CC/MCC
0.8787
744,MDC 13P,D&C, conization, laparoscopy & tubal interruption w CC/MCC
1.4699
745,MDC 13P,D&C, conization, laparoscopy & tubal interruption w/o CC/MCC
0.7721
746,MDC 13P,Vagina, cervix & vulva procedures w CC/MCC
1.2251
747,MDC 13P,Vagina, cervix & vulva procedures w/o CC/MCC
0.8471
748,MDC 13P,Female reproductive system reconstructive procedures
0.8784
749,MDC 13P,Other female reproductive system O.R. procedures w CC/MCC
2.4378
750,MDC 13P,Other female reproductive system O.R. procedures w/o CC/MCC
1.0159
754,MDC 13M,Malignancy, female reproductive system w MCC
1.8829
755,MDC 13M,Malignancy, female reproductive system w CC
1.1184
756,MDC 13M,Malignancy, female reproductive system w/o CC/MCC
0.5883
757,MDC 13M,Infections, female reproductive system w MCC
1.7189
758,MDC 13M,Infections, female reproductive system w CC
1.0980
759,MDC 13M,Infections, female reproductive system w/o CC/MCC
0.7719
760,MDC 13M,Menstrual & other female reproductive system disorders w CC/MCC
0.7992
761,MDC 13M,Menstrual & other female reproductive system disorders w/o CC/MCC
0.4952
765,MDC 14P,Cesarean section w CC/MCC
1.1083
766,MDC 14P,Cesarean section w/o CC/MCC
0.7526
767,MDC 14P,Vaginal delivery w sterilization &/or D&C
0.8389
768,MDC 14P,Vaginal delivery w O.R. proc except steril &/or D&C
1.7754
769,MDC 14P,Postpartum & post abortion diagnoses w O.R. procedure
1.8900
770,MDC 14P,Abortion w D&C, aspiration curettage or hysterotomy
0.5367
October 2009
Current MDCs and DRGs A.21
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
774,MDC 14M,Vaginal delivery w complicating diagnoses
0.6873
775,MDC 14M,Vaginal delivery w/o complicating diagnoses
0.4971
776,MDC 14M,Postpartum & post abortion diagnoses w/o O.R. procedure
0.6808
777,MDC 14M,Ectopic pregnancy
0.7786
778,MDC 14M,Threatened abortion
0.4229
779,MDC 14M,Abortion w/o D&C
0.4386
780,MDC 14M,False labor
0.2023
781,MDC 14M,Other antepartum diagnoses w medical complications
0.6357
782,MDC 14M,Other antepartum diagnoses w/o medical complications
0.4504
789,MDC 15M,Neonates, died or transferred to another acute care facility
1.4583
790,MDC 15M,Extreme immaturity or respiratory distress syndrome, neonate
4.8090
791,MDC 15M,Prematurity w major problems
3.2844
792,MDC 15M,Prematurity w/o major problems
1.9817
793,MDC 15M,Full term neonate w major problems
3.3738
794,MDC 15M,Neonate w other significant problems
1.1941
795,MDC 15M,Normal newborn
0.1617
799,MDC 16P,Splenectomy w MCC
5.1087
800,MDC 16P,Splenectomy w CC
2.5315
801,MDC 16P,Splenectomy w/o CC/MCC
1.5865
802,MDC 16P,Other O.R. proc of the blood & blood forming organs w MCC
3.4788
803,MDC 16P,Other O.R. proc of the blood & blood forming organs w CC
1.7680
804,MDC 16P,Other O.R. proc of the blood & blood forming organs w/o CC/MCC
1.0388
808,MDC 16M,Major hematol/immun diag exc sickle cell crisis & coagul w MCC
2.0487
809,MDC 16M,Major hematol/immun diag exc sickle cell crisis & coagul w CC
1.1725
810,MDC 16M,Major hematol/immun diag exc sickle cell crisis & coagul w/o CC/MCC
0.8689
811,MDC 16M,Red blood cell disorders w MCC
1.2431
812,MDC 16M,Red blood cell disorders w/o MCC
0.7751
813,MDC 16M,Coagulation disorders
1.3846
814,MDC 16M,Reticuloendothelial & immunity disorders w MCC
1.5144
815,MDC 16M,Reticuloendothelial & immunity disorders w CC
0.9596
816,MDC 16M,Reticuloendothelial & immunity disorders w/o CC/MCC
0.6953
820,MDC 17P,Lymphoma & leukemia w major O.R. procedure w MCC
5.3673
821,MDC 17P,Lymphoma & leukemia w major O.R. procedure w CC
2.2672
822,MDC 17P,Lymphoma & leukemia w major O.R. procedure w/o CC/MCC
1.1632
A.22 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
823,MDC 17P,Lymphoma & non-acute leukemia w other O.R. proc w MCC
3.9010
824,MDC 17P,Lymphoma & non-acute leukemia w other O.R. proc w CC
2.1520
825,MDC 17P,Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC
1.2003
826,MDC 17P,Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC
4.5104
827,MDC 17P,Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC
2.0111
828,MDC 17P,Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC
1.2384
829,MDC 17P,Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC
2.6088
830,MDC 17P,Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC
0.9784
834,MDC 17M,Acute leukemia w/o major O.R. procedure w MCC
4.3709
835,MDC 17M,Acute leukemia w/o major O.R. procedure w CC
2.4817
836,MDC 17M,Acute leukemia w/o major O.R. procedure w/o CC/MCC
1.2595
837,MDC 17M,Chemo w acute leukemia as sdx or w high dose chemo agent w MCC
6.3616
838,MDC 17M,Chemo w acute leukemia as sdx w CC or high dose chemo agent
3.0949
839,MDC 17M,Chemo w acute leukemia as sdx w/o CC/MCC
1.2496
840,MDC 17M,Lymphoma & non-acute leukemia w MCC
2.7258
841,MDC 17M,Lymphoma & non-acute leukemia w CC
1.5071
842,MDC 17M,Lymphoma & non-acute leukemia w/o CC/MCC
0.9803
843,MDC 17M,Other myeloprolif dis or poorly diff neopl diag w MCC
1.6852
844,MDC 17M,Other myeloprolif dis or poorly diff neopl diag w CC
1.1997
845,MDC 17M,Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC
0.8043
846,MDC 17M,Chemotherapy w/o acute leukemia as secondary diagnosis w MCC
2.1717
847,MDC 17M,Chemotherapy w/o acute leukemia as secondary diagnosis w CC
0.9451
848,MDC 17M,Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC
0.8235
849,MDC 17M,Radiotherapy
1.2837
853,MDC 18P,Infectious & parasitic diseases w O.R. procedure w MCC
5.4946
854,MDC 18P,Infectious & parasitic diseases w O.R. procedure w CC
2.7290
855,MDC 18P,Infectious & parasitic diseases w O.R. procedure w/o CC/MCC
1.7040
856,MDC 18P,Postoperative or post-traumatic infections w O.R. proc w MCC
4.9249
857,MDC 18P,Postoperative or post-traumatic infections w O.R. proc w CC
2.0439
858,MDC 18P,Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC
1.3521
862,MDC 18M,Postoperative & post-traumatic infections w MCC
1.9008
863,MDC 18M,Postoperative & post-traumatic infections w/o MCC
0.9702
864,MDC 18M,Fever
0.8153
865,MDC 18M,Viral illness w MCC
1.3601
October 2009
Current MDCs and DRGs A.23
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
866,MDC 18M,Viral illness w/o MCC
0.6736
867,MDC 18M,Other infectious & parasitic diseases diagnoses w MCC
2.3705
868,MDC 18M,Other infectious & parasitic diseases diagnoses w CC
1.0680
869,MDC 18M,Other infectious & parasitic diseases diagnoses w/o CC/MCC
0.7419
870,MDC 18M,Septicemia or severe sepsis w MV 96+ hours
5.8007
871,MDC 18M,Septicemia or severe sepsis w/o MV 96+ hours w MCC
1.8437
872,MDC 18M,Septicemia or severe sepsis w/o MV 96+ hours w/o MCC
1.1155
876,MDC 19P,O.R. procedure w principal diagnoses of mental illness
2.5892
880,MDC 19M,Acute adjustment reaction & psychosocial dysfunction
0.6191
881,MDC 19M,Depressive neuroses
0.6048
882,MDC 19M,Neuroses except depressive
0.6676
883,MDC 19M,Disorders of personality & impulse control
1.1188
884,MDC 19M,Organic disturbances & mental retardation
0.9452
885,MDC 19M,Psychoses
0.8899
886,MDC 19M,Behavioral & developmental disorders
0.7895
887,MDC 19M,Other mental disorder diagnoses
0.8336
894,MDC 20M,Alcohol/drug abuse or dependence, left ama
0.4021
895,MDC 20M,Alcohol/drug abuse or dependence w rehabilitation therapy
0.9742
896,MDC 20M,Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC
1.4155
897,MDC 20M,Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC
0.6288
901,MDC 21P,Wound debridements for injuries w MCC
4.0545
902,MDC 21P,Wound debridements for injuries w CC
1.7850
903,MDC 21P,Wound debridements for injuries w/o CC/MCC
1.0137
904,MDC 21P,Skin grafts for injuries w CC/MCC
2.8601
905,MDC 21P,Skin grafts for injuries w/o CC/MCC
1.0901
906,MDC 21P,Hand procedures for injuries
0.9991
907,MDC 21P,Other O.R. procedures for injuries w MCC
3.8072
908,MDC 21P,Other O.R. procedures for injuries w CC
1.8736
909,MDC 21P,Other O.R. procedures for injuries w/o CC/MCC
1.1135
913,MDC 21M,Traumatic injury w MCC
1.3473
914,MDC 21M,Traumatic injury w/o MCC
0.6789
915,MDC 21M,Allergic reactions w MCC
1.2545
916,MDC 21M,Allergic reactions w/o MCC
0.4513
917,MDC 21M,Poisoning & toxic effects of drugs w MCC
1.4449
A.24 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
918,MDC 21M,Poisoning & toxic effects of drugs w/o MCC
0.5839
919,MDC 21M,Complications of treatment w MCC
1.5883
920,MDC 21M,Complications of treatment w CC
0.9405
921,MDC 21M,Complications of treatment w/o CC/MCC
0.6121
922,MDC 21M,Other injury, poisoning & toxic effect diag w MCC
1.3114
923,MDC 21M,Other injury, poisoning & toxic effect diag w/o MCC
0.6556
927,MDC 22P,Extensive burns or full thickness burns w MV 96+ hrs w skin graft
13.7351
928,MDC 22P,Full thickness burn w skin graft or inhal inj w CC/MCC
5.3052
929,MDC 22P,Full thickness burn w skin graft or inhal inj w/o CC/MCC
2.0086
933,MDC 22M,Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft
2.3081
934,MDC 22M,Full thickness burn w/o skin grft or inhal inj
1.3403
935,MDC 22M,Non-extensive burns
1.2507
939,MDC 23P,O.R. proc w diagnoses of other contact w health services w MCC
2.8593
940,MDC 23P,O.R. proc w diagnoses of other contact w health services w CC
1.6821
941,MDC 23P,O.R. proc w diagnoses of other contact w health services w/o CC/MCC
1.1298
945,MDC 23M,Rehabilitation w CC/MCC
1.2388
946,MDC 23M,Rehabilitation w/o CC/MCC
1.1159
947,MDC 23M,Signs & symptoms w MCC
1.0922
948,MDC 23M,Signs & symptoms w/o MCC
0.6689
949,MDC 23M,Aftercare w CC/MCC
0.9758
950,MDC 23M,Aftercare w/o CC/MCC
0.5459
951,MDC 23M,Other factors influencing health status
0.7239
955,MDC 24P,Craniotomy for multiple significant trauma
5.6781
956,MDC 24P,Limb reattachment, hip & femur proc for multiple significant trauma
3.4364
957,MDC 24P,Other O.R. procedures for multiple significant trauma w MCC
6.2993
958,MDC 24P,Other O.R. procedures for multiple significant trauma w CC
3.6544
959,MDC 24P,Other O.R. procedures for multiple significant trauma w/o CC/MCC
2.2000
963,MDC 24M,Other multiple significant trauma w MCC
2.7687
964,MDC 24M,Other multiple significant trauma w CC
1.5026
965,MDC 24M,Other multiple significant trauma w/o CC/MCC
0.9781
969,MDC 25P,HIV w extensive O.R. procedure w MCC
5.5074
970,MDC 25P,HIV w extensive O.R. procedure w/o MCC
2.5627
974,MDC 25M,HIV w major related condition w MCC
2.4810
975,MDC 25M,HIV w major related condition w CC
1.3597
October 2009
Current MDCs and DRGs A.25
07/17/09
Preliminary
Table A–2. List of DRGs with cost weights
DRG, MDC, and DRG description
DRG cost weight
976,MDC 25M,HIV w major related condition w/o CC/MCC
0.8967
977,MDC 25M,HIV w or w/o other related condition
1.0538
981,MDC
P,Extensive O.R. procedure unrelated to principal diagnosis w MCC
5.0389
982,MDC
P,Extensive O.R. procedure unrelated to principal diagnosis w CC
2.8954
983,MDC
P,Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC
1.8072
984,MDC
P,Prostatic O.R. procedure unrelated to principal diagnosis w MCC
3.3443
985,MDC
P,Prostatic O.R. procedure unrelated to principal diagnosis w CC
1.9481
986,MDC
P,Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC
1.1079
987,MDC
P,Non-extensive O.R. proc unrelated to principal diagnosis w MCC
3.4020
988,MDC
P,Non-extensive O.R. proc unrelated to principal diagnosis w CC
1.7836
989,MDC
P,Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC
1.0358
998,MDC
,Principal diagnosis invalid as discharge diagnosis
0.0000
999,MDC
,Ungroupable
0.0000
A.26 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
07/17/09
Index
A
About box, 3.4
Accelerator keys
data entry window, 3.11
interactive output, 3.20
Accessing
batch processing, 4.4
interactive data entry, 3.4
MS-DOS prompt, 4.4
Add/Remove dialog, 2.7
Age conflict, 3.22
B
Batch processing, 4.3
accessing, 4.4
command examples, 4.11
entering a command line, 4.5
error messages, 4.19
flow chart overview, 4.4
input file, 4.6
log file, 4.21
optional information, 4.9
output files
formatted reports, 4.12
upload files, 4.12
output files and formats, 4.12
principal procedure edit return flag, 4.16
printing output, 4.18
processing options, 4.10
October 2009
renaming a file, 4.18
viewing output, 4.18
Bilateral procedure, 3.23
Buttons
data entry, 3.11
output report, 3.21
C
Clear button, 3.11
Close button, 3.21
Code edits
diagnoses, 3.22
procedures, 3.23
Command buttons
data entry window, 3.11
interactive output, 3.21
Command line, 4.5
examples, 4.11
processing options, 4.10
Cost weights for DRGs, A.4
D
Data entry fields, 3.7
Data entry window
accelerator keys, 3.11
command buttons, 3.11
error messages, 3.12
Index I.1
07/17/09
fields, 3.7
codes, 3.9
patient information, 3.7
patient stay information, 3.7
menu options, 3.11
Date format, 3.7, 3.8
Default batch processing log filename, 4.21
Default interactive output filename, 3.20
Default primary payer value, 3.7
Default program version used
interactive, 3.8, 3.17
Description files, 2.5
Discharge status values, 3.9
Discontinued edit, 3.22, 3.23
DRGs
cost weights, A.4
Duplicate of principal diagnosis, 3.22
E
E-code as principal diagnosis, 3.22
Edit
age conflict, 3.22
bilateral procedure, 3.23
duplicate of principal diagnosis, 3.22
E-code as principal diagnosis, 3.22
invalid age, 3.24
invalid discharge status, 3.24
invalid ICD-9-CM code, 3.22, 3.23
invalid sex, 3.24
limited coverage, 3.23
manifestation code as principal diagnosis, 3.22
non-covered procedure, 3.23
non-specific O.R. procedure, 3.23
non-specific principal diagnosis, 3.22
open biopsy check, 3.24
questionable admission, 3.22
secondary payer alert (MSP), 3.22
sex conflict, 3.22, 3.24
unacceptable principal diagnosis, 3.23
Edit return flag in batch processing
principal procedure, 4.16
Edits
batch processing, 4.15
description, 3.22
discontinued, 3.22, 3.23
pre- and post-payment errors, 3.19
Error messages
batch processing, 4.19
interactive, 3.12
pre- and post-payment, 3.19
Example
batch processing commands, 4.11
interactive output report, 3.14
I.2 MS Grouper with Medicare Code Editor Software
Preliminary
log file, 4.21
F
Fields
batch input, 4.6
batch upload, 4.13
interactive
data entry, 3.7
output, 3.16
File
batch input, 4.4
record layout, 4.6
batch output, 4.12
interactive output, 3.20
log, 4.21
upload, 4.12
record layout, 4.13
Formatted
batch output, 4.12
interactive output, 3.15
Functions installed, 2.6
G
Grouper selection, 1.3, 3.4
H
Hardware requirements, 2.3
How to
change data on the output report, 3.15
clear the Code fields, 3.11
close the output report window, 3.21
copy text, 3.11, 3.20
cut text, 3.11
delete text, 3.11
display a new window for data entry, 3.11
display the About box, 3.11
display the interactive output report, 3.11, 3.13
enter data in batch processing, 4.4
enter data interactively, 3.4
exit the output report window, 3.20
exit the program, 3.11
format a batch input file, 4.6
paste text, 3.11
print a log file, 4.22
print an interactive output report, 3.20
print batch output, 4.18
rename a file, 4.18, 4.22
run batch processing, 4.4
save an interactive output report, 3.20
October 2009
Preliminary
07/17/09
select all text, 3.20
uninstall the software, 2.7
view a log file, 4.22
view batch output, 4.18
view interactive output, 3.15
write a batch command, 4.11
I
Input file
batch processing, 4.6
optional information, 4.9
Installation procedure, 2.4
pre-install notes, 2.3
previously installed versions, 2.3
Installed program functions, 2.6
Interactive data entry, 3.4
Interactive data processing, 3.3
Interactive output report, 3.15
accelerator keys, 3.20
command buttons, 3.21
edits, 3.22
example, 3.14
fields, 3.16
menu options, 3.20
Invalid age, 3.24
Invalid discharge status, 3.24
Invalid ICD-9-CM code, 3.22, 3.23
Invalid sex, 3.24
Menu options
data entry window, 3.11
interactive output, 3.20
MS-DOS prompt, 4.4
MSP alert, 3.22
N
Non-covered procedure, 3.23
Non-specific O.R. procedure, 3.23
Non-specific principal diagnosis, 3.22
O
Open biopsy check, 3.24
Optional information, batch processing, 4.9, 4.12
Options in batch processing, 4.10
Output files, batch processing, 4.12
formatted reports, 4.12
upload, 4.12
Output report
batch processing, 4.12
example, 3.14
interactive, 3.15
accelerator keys, 3.20
command buttons, 3.21
edits, 3.22
fields, 3.16
menu options, 3.20
Overview of batch processing, 4.4
K
Keys, accelerator
data entry window, 3.11
output report, 3.20
L
Limited coverage, 3.23
Lists
DRGs
cost weights, A.4
MDCs, A.3
Log files, 4.21
printing, 4.22
renaming, 4.22
viewing, 4.22
M
Manifestation code as principal diagnosis, 3.22
MDCs, list of, A.3
October 2009
P
Post-payment error, 3.19
Pre-installation notes, 2.3
Pre-payment error, 3.19
Previously installed versions, 2.3
Primary payer values, 3.7
default, 3.7
Printing
a log file, 4.22
batch output, 4.18
Processing options in batch processing, 4.10
Product description, 1.3
Program functions, 2.6
Program output
batch processing, 4.12
interactive, 3.15
Q
Questionable admission, 3.22
Index
I.3
07/17/09
Preliminary
R
Record layout
batch input file, 4.6
batch upload file, 4.13
Remove the product, 2.7
Renaming
a log file, 4.22
the batch output file, 4.18
Report button, 3.11
Requirements for installation, 2.3
Requires secondary diagnosis, 3.23
S
Secondary payer alert (MSP alert), 3.22
Sex conflict, 3.22, 3.24
System requirements, 2.3
U
Unacceptable principal diagnosis, 3.23
Uninstall the product, 2.7
Uninstalling the software, 2.7
Upload file, 4.12
record layout, 4.13
V
Versions of the program, 1.4
Viewing
a log file, 4.22
batch output, 4.18
interactive output, 3.15
W
Window
interactive output report, 3.20
MS-DOS, 4.4
I.4 MS Grouper with Medicare Code Editor Software
October 2009
Preliminary
06/12/09
Definitions of Medicare Code Edits
PBL–011 October 2009
06/12/09
Document number
October 2009
Preliminary
PBL–011
ii Definitions of Medicare Code Edits
October 2009
Preliminary
06/12/09
About this document
T
HE MEDICARE CODE EDITOR (MCE) detects and reports
errors in the coding claims data. This manual contains a
description of each coding edit with corresponding ICD-9-CM code
lists.
The coding edit information in this manual is effective from
10/01/2009 to 09/30/2010.
October 2009
iii
06/12/09
iv Definitions of Medicare Code Edits
Preliminary
October 2009
Preliminary
06/12/09
Contents
Preface
Chapter 1
About this document iii
Edit code lists
1.3
1. Invalid diagnosis or procedure code 1.4
2. E-code as principal diagnosis 1.4
3. Duplicate of PDX 1.4
4. Age conflict 1.4
5. Sex conflict 1.19
6. Manifestation code as principal diagnosis 1.38
7. Non-specific principal diagnosis 1.41
8. Questionable admission 1.41
9. Unacceptable principal diagnosis 1.42
10. Non-specific O.R. procedure 1.50
11. Non-covered procedure 1.50
12. Open biopsy check 1.53
13. Bilateral procedure 1.54
14. Invalid age 1.55
15. Invalid sex 1.55
16. Invalid discharge status 1.55
17. Limited coverage 1.56
18. Wrong procedure performed 1.57
Chapter 2
Code list changes
2.3
Changes to existing edits
New edit 2.13
Index
October 2009
2.3
I.1
Contents v
06/12/09
vi Definitions of Medicare Code Edits
Preliminary
October 2009
Chapter 1
Edit code lists
1
Contents
Edit code lists
1.3
1. Invalid diagnosis or procedure code 1.4
2. E-code as principal diagnosis 1.4
3. Duplicate of PDX 1.4
4. Age conflict 1.4
5. Sex conflict 1.19
6. Manifestation code as principal diagnosis 1.38
7. Non-specific principal diagnosis 1.41
8. Questionable admission 1.41
9. Unacceptable principal diagnosis 1.42
10. Non-specific O.R. procedure 1.50
11. Non-covered procedure 1.50
12. Open biopsy check 1.53
13. Bilateral procedure 1.54
14. Invalid age 1.55
15. Invalid sex 1.55
16. Invalid discharge status 1.55
17. Limited coverage 1.56
18. Wrong procedure performed 1.57
1.2 Definitions of Medicare Code Edits
October 2009
Chapter 1
Edit code lists
BELOW IS A LIST of current edits described in this chapter.
October 2009
1.
Invalid diagnosis or procedure code
2.
E-code as principal diagnosis
3.
Duplicate of PDX
4.
Age conflict
5.
Sex conflict
6.
Manifestation code as principal diagnosis
7.
Non-specific principal diagnosis (Discontinued as of 10/01/07)
8.
Questionable admission
9.
Unacceptable principal diagnosis
10.
Non-specific O.R. procedure (Discontinued as of 10/01/07)
11.
Non-covered procedure
12.
Open biopsy check
13.
Bilateral procedure
14.
Invalid age
15.
Invalid sex
16.
Invalid discharge status
17.
Limited coverage
18.
Wrong procedure performed
Edit code lists 1.3
Invalidordiagnosis
or
1. Invalid1.
diagnosis
procedure code
procedure code
E-code
as principal
2. 2.
E-code
as principal
diagnosis
diagnosis
The Medicare Code Editor checks each diagnosis including the admitting diagnosis and each procedure against a table of valid ICD-9-CM
codes. If an entered code does not agree with any code on the internal
list, it is assumed to be invalid or that the 4th or 5th digit of the code is
invalid or missing.
For a list of all valid ICD-9-CM codes, see volumes 2 (diseases) and 3
(procedures) of the International Classification of Diseases, 9th Revision, Fourth Edition, Clinical Modification (ICD-9-CM).
E-codes are ICD-9-CM codes beginning with the letter E. They
describe the circumstance causing an injury, not the nature of the
injury, and therefore should not be used as a principal diagnosis.
For a list of all E-codes, see volume 2 (diseases) of the International
Classification of Diseases, 9th Revision, Fourth Edition, Clinical
Modification (ICD-9-CM).
3. Duplicate of PDX
4. Age conflict
Whenever a secondary diagnosis is coded the same as the principal
diagnosis, the secondary diagnosis is identified as a duplicate of the
principal diagnosis.
The Medicare Code Editor 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.
In the above cases, the diagnosis is clinically and virtually impossible
in a patient of the stated age. Therefore, either the diagnosis or the age
is presumed to be incorrect. There are four age categories for diagnoses in the program:
◆
Newborn. Age of 0 years; a subset of diagnoses intended only for
newborns and neonates (e.g., fetal distress, perinatal jaundice).
◆
Pediatric. Age range is 0–17 years inclusive (e.g., Reye’s syndrome, routine child health exam).
◆
Maternity. Age range is 12–55 years inclusive (e.g., diabetes in
pregnancy, antepartum pulmonary complication).
◆
Adult. Age range is 15–124 years inclusive (e.g., senile delirium,
mature cataract).
The following pages contain lists of ICD-9-CM diagnosis codes with
corresponding English descriptions for each of the age categories
described above.
1.4 Definitions of Medicare Code Edits
October 2009
Newborn diagnoses
27701
74783
76077
76078
7620
7621
7622
7623
7624
7625
7626
7627
7628
7629
7630
7631
7632
7633
7634
7635
7636
7637
76381
76382
76383
76384
76389
7639
76400
76401
76402
76403
76404
76405
76406
76407
76408
76409
76410
76411
76412
76413
76414
76415
76416
76417
76418
76419
76420
76421
76422
76423
76424
76425
76426
76427
76428
76429
76490
76491
76492
76493
76494
76495
76496
Cystic fibrosis w ileus
Persistent fetal circ
Mat anticonv aff NB/fet
Mat antimetabol aff NB
Placenta previa aff NB
Placenta hem NEC aff NB
Abn plac NEC/NOS aff NB
Placent transfusion syn
Prolapsed cord aff NB
Oth umbil cord compress
Umbil cond NEC aff NB
Chorioamnionitis aff NB
Abn amnion NEC aff NB
Abn amnion NOS aff NB
Breech del/extrac aff NB
Malpos/dispro NEC aff NB
Forceps delivery aff NB
Vacuum extrac del aff NB
Cesarean delivery aff NB
Mat anesth/analg aff NB
Precipitate del aff NB
Abn uterine contr aff NB
Ab ftl hrt rt/rh b/f lab
Ab ftl hrt rt/rh dur lab
Ab ftl hrt rt/rhy NOS
Meconium dur del aff NB
Compl del NEC aff NB
Compl deliv NOS aff NB
Light-for-dates wtNOS
Light-for-dates <500g
Lt-for-dates 500-749g
Lt-for-dates 750-999g
Lt-for-dates 1000-1249g
Lt-for-dates 1250-1499g
Lt-for-dates 1500-1749g
Lt-for-dates 1750-1999g
Lt-for-dates 2000-2499g
Lt-for-dates 2500+g
Lt-for-date w/mal wtNOS
Lt-for-date w/mal <500g
Lt-date w/mal 500-749g
Lt-date w/mal 750-999g
Lt-date w/mal 1000-1249g
Lt-date w/mal 1250-1499g
Lt-date w/mal 1500-1749g
Lt-date w/mal 1750-1999g
Lt-date w/mal 2000-2499g
Lt-for-date w/mal 2500+g
Fetal malnutrition wtNOS
Fetal malnutrition <500g
Fetal malnutr 500-749g
Fetal mal 750-999g
Fetal mal 1000-1249g
Fetal mal 1250-1499g
Fetal mal 1500-1749g
Fetal malnutr 1750-1999g
Fetal malnutr 2000-2499g
Fetal malnutr 2500+g
Fet growth retard wtNOS
Fet growth retard <500g
Fet growth ret 500-749g
Fet growth ret 750-999g
Fet grwth ret 1000-1249g
Fet grwth ret 1250-1499g
Fet grwth ret 1500-1749g
October 2009
76497
76498
76499
76500
76501
76502
76503
76504
76505
76506
76507
76508
76509
76510
76511
76512
76513
76514
76515
76516
76517
76518
76519
76520
76521
76522
76523
76524
76525
76526
76527
76528
76529
7660
7661
76621
76622
7670
76711
76719
7672
7673
7674
7675
7676
7677
7678
7679
7680
7681
7682
7683
7684
7685
7686
76870
76871
76872
76873
7689
769
7700
77010
77011
77012
Fet grwth ret 1750-1999g
Fet grwth ret 2000-2499g
Fet growth ret 2500+g
Extreme immatur wtNOS
Extreme immatur <500g
Extreme immatur 500-749g
Extreme immatur 750-999g
Extreme immat 1000-1249g
Extreme immat 1250-1499g
Extreme immat 1500-1749g
Extreme immat 1750-1999g
Extreme immat 2000-2499g
Extreme immat 2500+g
Preterm infant NEC wtNOS
Preterm NEC <500g
Preterm NEC 500-749g
Preterm NEC 750-999g
Preterm NEC 1000-1249g
Preterm NEC 1250-1499g
Preterm NEC 1500-1749g
Preterm NEC 1750-1999g
Preterm NEC 2000-2499g
Preterm NEC 2500+g
Weeks of gestation NOS
<24 comp wks gestation
24 comp weeks gestation
25-26 comp wks gestation
27-28 comp wks gestation
29-30 comp wks gestation
31-32 comp wks gestation
33-34 comp wks gestation
35-36 comp wks gestation
37+ comp wks gestation
Exceptionally large baby
Heavy-for-date infan NEC
Post-term infant
Prolong gestation-infant
Cerebral hem at birth
Epicranial subapo hemorr
Injuries to scalp NEC
Clavicle fx at birth
Bone injury NEC at birth
Spinal cord inj at birth
Facial nerve inj-birth
Brach plexus inj-birth
Nerve inj NEC at birth
Birth trauma NEC
Birth trauma NOS
Fetal death-anoxia NOS
Fet death-anoxia dur lab
Fet distress befor labor
Fetal distrs dur lab/del
Fetal distress NOS
Severe birth asphyxia
Mild/mod birth asphyxia
Hypoxc-ischem enceph NOS
Mild hypox-ischem enceph
Mod hypox-ischem enceph
Sev hypox-ischem enceph
Birth asphyxia NOS
Respiratory distress syn
Congenital pneumonia
Fetal & newborn asp NOS
Meconium asp wo resp sym
Meconium asp w resp symp
Edit code lists 1.5
Newborn diagnoses
77013
77014
77015
77016
77017
77018
7702
7703
7704
7705
7706
77081
77082
77083
77084
77085
77086
77087
77088
77089
7709
7710
7711
7712
7713
7714
7715
7716
7717
77181
77182
77183
77189
7720
77210
77211
77212
77213
77214
7722
7723
7724
7725
7726
7728
7729
7730
7731
7732
7733
7734
7735
7740
7741
7742
77430
77431
77439
7744
7745
7746
7747
7750
7751
7752
7753
7754
7755
Amniotc asp w/o resp sym
Amniotic asp w resp sym
Blood asp w/o resp sympt
Blood asp w resp sympt
NB asp w/o resp symp NEC
NB asp w resp symp NEC
NB interstit emphysema
NB pulmonary hemorrhage
Primary atelectasis
NB atelectasis NEC/NOS
NB transitory tachypnea
Primary apnea of newborn
Other apnea of newborn
Cyanotic attack, newborn
Resp failure of newborn
Stomch cont asp w/o resp
Stomach cont asp w resp
NB respiratory arrest
NB hypoxia
Resp prob after brth NEC
NB respiratory cond NOS
Congenital rubella
Cong cytomegalovirus inf
Congenital infec NEC
Tetanus neonatorum
Omphalitis of newborn
Neonatal infec mastitis
Neonatal conjunctivitis
Neonatal candida infect
NB septicemia [sepsis]
NB urinary tract infectn
Bacteremia of newborn
Perinatal infection NEC
NB fetal blood loss NEC
NB intraven hem NOS
NB intraven hem,grade i
NB intraven hem,grade ii
NB intravn hem,grade iii
NB intraven hem,grade iv
NB subarachnoid hemorr
Post-birth umbil hemorr
NB GI hemorrhage
NB adrenal hemorrhage
NB cutaneous hemorrhage
Neonatal hemorrhage NEC
Neonatal hemorrhage NOS
NB hemolyt dis:rh isoimm
NB hemolyt dis-abo isoim
NB hemolyt dis-isoim NEC
Hydrops fetalis:isoimm
NB kernicterus:isoimmun
NB late anemia:isoimmun
Perinat jaund-hered anem
Perinat jaund:hemolysis
Neonat jaund preterm del
Delay conjugat jaund NOS
Neonat jaund in oth dis
Delay conjugat jaund NEC
Fetal/neonatal hepatitis
Perinatal jaundice NEC
Fetal/neonatal jaund NOS
NB kernicterus
Infant diabet mother syn
Neonat diabetes mellitus
Neonat myasthenia gravis
Neonatal thyrotoxicosis
Hypocalcem/hypomagnes NB
Neonatal dehydration
1.6 Definitions of Medicare Code Edits
7756
7757
77581
77589
7759
7760
7761
7762
7763
7764
7765
7766
7767
7768
7769
7771
7772
7773
7774
77750
77751
77752
77753
7776
7778
7779
7780
7781
7782
7783
7784
7785
7787
7788
7789
7790
7791
7792
77931
77932
77933
77934
7794
7795
7796
77981
77982
77983
77984
77985
77989
7799
78092
7966
V2031
V2032
V290
V291
V292
V293
V298
V299
V3000
V3001
V301
V3100
V3101
V311
Neonatal hypoglycemia
Late metab acidosis NB
NB acidosis NEC
Neonat endo/met dis NEC
Transient met dis NB NOS
NB hemorrhagic disease
Neonatal thrombocytopen
Dissem intravasc coag NB
Oth neonatal coag dis
Polycythemia neonatorum
Congenital anemia
Anemia of prematurity
Neonatal neutropenia
Transient hemat dis NEC
NB hematological dis NOS
Meconium obstruction
Intest obst-inspiss milk
Swallowed blood syndrome
Transitory ileus of NB
Nec enterocoltis NB NOS
Stg I nec enterocol NB
Stg II nec enterocol NB
Stg III nec enterocol NB
Perinatal intest perfor
Perinat GI sys dis NEC
Perinat GI sys dis NOS
Hydrops fetalis no isoim
Sclerema neonatorum
NB cold injury syndrome
NB hypothermia NEC
NB temp regulat dis NEC
Edema of newborn NEC/NOS
NB breast engorgement
NB integument cond NEC
NB integument cond NOS
Convulsions in newborn
NB cereb irrit NEC/NOS
Cns dysfunction syn NB
NB feeding problems
NB bilious vomiting
NB other vomiting
NB failure to thrive
NB drug reaction/intoxic
NB drug withdrawal syndr
Termination of pregnancy
Neonatal bradycardia
Neonatal tachycardia
Delay separate umbl cord
Meconium staining
NB cardiac arrest
Perinatal condition NEC
Perinatal condition NOS
Excess cry infant/baby
Abnorm neonate screening
Health supvsn nb <8 days
Health supv nb 8-28 days
NB obsrv suspct infect
NB obsrv suspct neurlgcl
Obsrv NB suspc resp cond
NB obs genetc/metabl cnd
NB obsrv oth suspct cond
NB obsrv unsp suspct cnd
Single lb in-hosp w/o cs
Single lb in-hosp w cs
Singl livebrn-before adm
Twin-mate lb-hosp w/o cs
Twin-mate lb-in hos w cs
Twin, mate lb-before adm
October 2009
Newborn diagnoses
V3200
V3201
V321
V3300
V3301
V331
V3400
V3401
V341
V3500
V3501
V351
V3600
V3601
V361
V3700
V3701
V371
V3900
V3901
V391
Twin-mate sb-hosp w/o cs
Twin-mate sb-hosp w cs
Twin, mate sb-before adm
Twin-NOS-in hosp w/o cs
Twin-NOS-in hosp w cs
Twin NOS-before admissn
Oth mult lb-hosp w/o cs
Oth mult lb-in hosp w cs
Oth mult nb-before adm
Oth mult sb-hosp w/o cs
Oth mult sb-in hosp w cs
Oth mult sb-before adm
Mult lb/sb-in hos w/o cs
Mult lb/sb-in hosp w cs
Mult nb/sb-before adm
Mult brth NOS-hos w/o cs
Mult birth NOS-hosp w cs
Mult brth NOS-before adm
Liveborn NOS-hosp w/o cs
Liveborn NOS-hosp w cs
Liveborn NOS-before adm
October 2009
Edit code lists 1.7
Pediatric diagnoses (age 0 through 17)
04041
05810
05811
05812
2591
31389
3139
33181
69011
69012
7511
7512
75161
78091
78341
78342
7897
7980
79982
99550
99551
99552
99553
99554
99555
99559
V200
V201
V202
V695
V8551
V8552
V8553
V8554
Infant botulism
Roseola infantum NOS
Roseola infant d/t HHV-6
Roseola infant d/t HHV-7
Sexual precocity NEC
Emotional dis child NEC
Emotional dis child NOS
Reye's syndrome
Seborrhea capitis
Sbrheic infantl drmtitis
Atresia small intestine
Atresia large intestine
Biliary atresia
Fussy infant/baby
Failure to thrive-child
Delayed milestones
Colic
Sudden infant death synd
Appar life threat-infant
Child abuse NOS
Child emotnl/psych abuse
Child neglect-nutrition
Child sexual abuse
Child physical abuse
Shaken infant syndrome
Child abuse/neglect NEC
Foundling health care
Care of healthy chld NEC
Routin child health exam
Behav insomnia-childhood
BMI,pediatric <5%
BMI,pediatric 5% - <85%
BMI,pediatric 85% - <95%
BMI,pediatric >= 95%
1.8 Definitions of Medicare Code Edits
October 2009
Maternity diagnoses (age 12 through 55)
630
631
632
63300
63301
63310
63311
63320
63321
63380
63381
63390
63391
63400
63401
63402
63410
63411
63412
63420
63421
63422
63430
63431
63432
63440
63441
63442
63450
63451
63452
63460
63461
63462
63470
63471
63472
63480
63481
63482
63490
63491
63492
63500
63501
63502
63510
63511
63512
63520
63521
63522
63530
63531
63532
63540
63541
63542
63550
63551
63552
63560
63561
63562
63570
Hydatidiform mole
Oth abn prod conception
Missed abortion
Abd preg w/o intrau preg
Abd preg w intraut preg
Tubal preg w/o intra prg
Tubal preg w intra preg
Ovarn preg w/o intra prg
Ovarian preg w intra prg
Ect preg NEC w/o int prg
Ectpc prg NEC w int preg
Ect preg NOS w/o int prg
Ectp preg NOS w int preg
Spon abor w pel inf-unsp
Spon abor w pelv inf-inc
Spon abor w pel inf-comp
Spon abort w hemorr-unsp
Spon abort w hemorr-inc
Spon abort w hemorr-comp
Spon ab w pel damag-unsp
Spon ab w pelv damag-inc
Spon ab w pel damag-comp
Spon ab w ren fail-unsp
Spon ab w ren fail-inc
Spon ab w ren fail-comp
Spon ab w metab dis-unsp
Spon ab w metab dis-inc
Spon ab w metab dis-comp
Spon abort w shock-unsp
Spon abort w shock-inc
Spon abort w shock-comp
Spon abort w embol-unsp
Spon abort w embol-inc
Spon abort w embol-comp
Spon ab w compl NEC-unsp
Spon ab w compl NEC-inc
Spon ab w compl NEC-comp
Spon ab w compl NOS-unsp
Spon ab w compl NOS-inc
Spon ab w compl NOS-comp
Spon abort uncompl-unsp
Spon abort uncompl-inc
Spon abort uncompl-comp
Leg abor w pelv inf-unsp
Leg abor w pelv inf-inc
Leg abor w pelv inf-comp
Legal abor w hemorr-unsp
Legal abort w hemorr-inc
Legal abor w hemorr-comp
Leg ab w pelv damag-unsp
Leg ab w pelv damag-inc
Leg ab w pelv damag-comp
Leg abor w ren fail-unsp
Leg abor w ren fail-inc
Leg abor w ren fail-comp
Leg ab w metab dis-unsp
Leg ab w metab dis-inc
Leg ab w metab dis-comp
Legal abort w shock-unsp
Legal abort w shock-inc
Legal abort w shock-comp
Legal abort w embol-unsp
Legal abort w embol-inc
Legal abort w embol-comp
Leg ab w compl NEC-unsp
October 2009
63571
63572
63580
63581
63582
63590
63591
63592
63600
63601
63602
63610
63611
63612
63620
63621
63622
63630
63631
63632
63640
63641
63642
63650
63651
63652
63660
63661
63662
63670
63671
63672
63680
63681
63682
63690
63691
63692
63700
63701
63702
63710
63711
63712
63720
63721
63722
63730
63731
63732
63740
63741
63742
63750
63751
63752
63760
63761
63762
63770
63771
63772
63780
63781
63782
Leg ab w compl NEC-inc
Leg ab w compl NEC-comp
Leg ab w compl NOS-unsp
Leg ab w compl NOS-inc
Leg ab w compl NOS-comp
Legal abort uncompl-unsp
Legal abort uncompl-inc
Legal abort uncompl-comp
Illeg ab w pelv inf-unsp
Illeg ab w pelv inf-inc
Illeg ab w pelv inf-comp
Illeg ab w hemorr-unspec
Illeg ab w hemorr-inc
Illeg ab w hemorr-comp
Illeg ab w pel damg-unsp
Illeg ab w pel damag-inc
Illeg ab w pel damg-comp
Illeg ab w ren fail-unsp
Illeg ab w ren fail-inc
Illeg ab w ren fail-comp
Illeg ab w met dis-unsp
Illeg ab w metab dis-inc
Illeg ab w met dis-comp
Illeg abort w shock-unsp
Illeg abort w shock-inc
Illeg abort w shock-comp
Illeg ab w embolism-unsp
Illeg ab w embolism-inc
Illeg ab w embolism-comp
Illg ab w compl NEC-unsp
Illeg ab w compl NEC-inc
Illg ab w compl NEC-comp
Illg ab w compl NOS-unsp
Illeg ab w compl NOS-inc
Illg ab w compl NOS-comp
Illeg abort uncompl-unsp
Illeg abort uncompl-inc
Illeg abort uncompl-comp
Abort NOS w pel inf-unsp
Abort NOS w pel inf-inc
Abort NOS w pel inf-comp
Abort NOS w hemorr-unsp
Abort NOS w hemorr-inc
Abort NOS w hemorr-comp
Ab NOS w pelv damag-unsp
Ab NOS w pelv damag-inc
Ab NOS w pelv damag-comp
Ab NOS w renal fail-unsp
Ab NOS w renal fail-inc
Ab NOS w renal fail-comp
Ab NOS w metab dis-unsp
Ab NOS w metab dis-inc
Ab NOS w metab dis-comp
Abort NOS w shock-unsp
Abort NOS w shock-inc
Abort NOS w shock-comp
Ab NOS w embolism-unsp
Ab NOS w embolism-inc
Ab NOS w embolism-comp
Ab NOS w compl NEC-unsp
Ab NOS w compl NEC-inc
Ab NOS w compl NEC-comp
Ab NOS w compl NOS-unsp
Ab NOS w compl NOS-inc
Ab NOS w compl NOS-comp
Edit code lists 1.9
Maternity diagnoses (age 12 through 55)
63790
63791
63792
6380
6381
6382
6383
6384
6385
6386
6387
6388
6389
6390
6391
6392
6393
6394
6395
6396
6398
6399
64000
64001
64003
64080
64081
64083
64090
64091
64093
64100
64101
64103
64110
64111
64113
64120
64121
64123
64130
64131
64133
64180
64181
64183
64190
64191
64193
64200
64201
64202
64203
64204
64210
64211
64212
64213
64214
64220
64221
64222
64223
64224
64230
64231
64232
64233
Ab NOS uncomplicat-unsp
Ab NOS uncomplicat-inc
Ab NOS uncomplicat-comp
Attem abort w pelvic inf
Attem abort w hemorrhage
Attem abort w pelv damag
Attem abort w renal fail
Attem abor w metabol dis
Attem abortion w shock
Attemp abort w embolism
Attemp abort w compl NEC
Attemp abort w compl NOS
Attempted abort uncompl
Postabortion gu infect
Postabortion hemorrhage
Postabort pelvic damage
Postabort kidney failure
Postabort metabolic dis
Postabortion shock
Postabortion embolism
Postabortion compl NEC
Postabortion compl NOS
Threatened abort-unspec
Threatened abort-deliver
Threaten abort-antepart
Hem early preg NEC-unsp
Hem early preg NEC-deliv
Hem early pg NEC-antepar
Hemorr early preg-unspec
Hem early preg-delivered
Hem early preg-antepart
Placenta previa-unspec
Placenta previa-deliver
Placenta previa-antepart
Placenta prev hem-unspec
Placenta prev hem-deliv
Placen prev hem-antepart
Prem separ placen-unspec
Prem separ placen-deliv
Prem separ plac-antepart
Coag def hemorr-unspec
Coag def hemorr-deliver
Coag def hemorr-antepart
Antepart hem NEC-unspec
Antepartum hem NEC-deliv
Antepart hem NEC-antepar
Antepart hem NOS-unspec
Antepartum hem NOS-deliv
Antepart hem NOS-antepar
Essen hyperten preg-unsp
Essen hyperten-delivered
Essen hyperten-del w p/p
Essen hyperten-antepart
Essen hyperten-postpart
Renal hyperten preg-unsp
Renal hyperten pg-deliv
Renal hyperten-del p/p
Renal hyperten-antepart
Renal hyperten-postpart
Old hyperten preg-unspec
Old hyperten NEC-deliver
Old hyperten-deliv w p/p
Old hyperten NEC-antepar
Old hyperten NEC-postpar
Trans hyperten preg-unsp
Trans hyperten-delivered
Trans hyperten-del w p/p
Trans hyperten-antepart
1.10 Definitions of Medicare Code Edits
64234
64240
64241
64242
64243
64244
64250
64251
64252
64253
64254
64260
64261
64262
64263
64264
64270
64271
64272
64273
64274
64290
64291
64292
64293
64294
64300
64301
64303
64310
64311
64313
64320
64321
64323
64380
64381
64383
64390
64391
64393
64400
64403
64410
64413
64420
64421
64510
64511
64513
64520
64521
64523
64600
64601
64603
64610
64611
64612
64613
64614
64620
64621
64622
64623
64624
64630
64631
Trans hyperten-postpart
Mild/NOS preeclamp-unsp
Mild/NOS preeclamp-deliv
Mild preeclamp-del w p/p
Mild/NOS preeclamp-antep
Mild/NOS preeclamp-p/p
Severe preeclamp-unspec
Severe preeclamp-deliver
Sev preeclamp-del w p/p
Sev preeclamp-antepartum
Sev preeclamp-postpartum
Eclampsia-unspecified
Eclampsia-delivered
Eclampsia-deliv w p/p
Eclampsia-antepartum
Eclampsia-postpartum
Tox w old hyperten-unsp
Tox w old hyperten-deliv
Tox w old hyp-del w p/p
Tox w old hyper-antepart
Tox w old hyper-postpart
Hyperten preg NOS-unspec
Hypertens NOS-delivered
Hypertens NOS-del w p/p
Hypertens NOS-antepartum
Hypertens NOS-postpartum
Mild hyperem grav-unspec
Mild hyperem grav-deliv
Mild hyperemesis-antepar
Hyperem w metab dis-unsp
Hyperem w metab dis-del
Hyperem w metab-antepart
Late vomit of preg-unsp
Late vomit of preg-deliv
Late vomit preg-antepart
Vomit compl preg-unspec
Vomit compl preg-deliver
Vomit compl preg-antepar
Vomit of preg NOS-unspec
Vomit of preg NOS-deliv
Vomit of pg NOS-antepart
Threat prem labor-unspec
Thrt prem labor-antepart
Threat labor NEC-unspec
Threat labor NEC-antepar
Early onset deliv-unspec
Early onset delivery-del
Post term preg-unsp
Post term preg-del
Post term preg-antepar
Prolonged preg-unsp
Prolonged preg-del
Prolonged preg-antepar
Papyraceous fetus-unspec
Papyraceous fetus-deliv
Papyraceous fet-antepar
Edema in preg-unspec
Edema in preg-delivered
Edema in preg-del w p/p
Edema in preg-antepartum
Edema in preg-postpartum
Renal dis preg NOS-unsp
Renal dis NOS-delivered
Renal dis NOS-del w p/p
Renal dis NOS-antepartum
Renal dis NOS-postpartum
Habitual aborter-unspec
Habitual aborter-deliver
October 2009
Maternity diagnoses (age 12 through 55)
64633
64640
64641
64642
64643
64644
64650
64651
64652
64653
64654
64660
64661
64662
64663
64664
64670
64671
64673
64680
64681
64682
64683
64684
64690
64691
64693
64700
64701
64702
64703
64704
64710
64711
64712
64713
64714
64720
64721
64722
64723
64724
64730
64731
64732
64733
64734
64740
64741
64742
64743
64744
64750
64751
64752
64753
64754
64760
64761
64762
64763
64764
64780
64781
64782
64783
64784
64790
Habitual abort-antepart
Neuritis of preg-unspec
Neuritis-delivered
Neuritis-delivered w p/p
Neuritis of preg-antepar
Neuritis of preg-postpar
Bacteriuria preg-unspec
Asym bacteriuria-deliver
Asy bacteruria-del w p/p
Asy bacteriuria-antepart
Asy bacteriuria-postpart
Gu infect in preg-unspec
Gu infection-delivered
Gu infection-deliv w p/p
Gu infection-antepartum
Gu infection-postpartum
Liver dis in preg-unspec
Liver disorder-delivered
Liver disorder-antepart
Preg compl NEC-unspec
Preg compl NEC-delivered
Preg compl NEC-del w p/p
Preg compl NEC-antepart
Preg compl NEC-postpart
Preg compl NOS-unspec
Preg compl NOS-delivered
Preg compl NOS-antepart
Syphilis in preg-unspec
Syphilis-delivered
Syphilis-delivered w p/p
Syphilis-antepartum
Syphilis-postpartum
Gonorrhea in preg-unspec
Gonorrhea-delivered
Gonorrhea-deliver w p/p
Gonorrhea-antepartum
Gonorrhea-postpartum
Other VD in preg-unspec
Other vd-delivered
Other vd-delivered w p/p
Other vd-antepartum
Other vd-postpartum
TB in preg-unspecified
Tuberculosis-delivered
Tuberculosis-deliv w p/p
Tuberculosis-antepartum
Tuberculosis-postpartum
Malaria in preg-unspec
Malaria-delivered
Malaria-delivered w p/p
Malaria-antepartum
Malaria-postpartum
Rubella in preg-unspec
Rubella-delivered
Rubella-delivered w p/p
Rubella-antepartum
Rubella-postpartum
Oth virus in preg-unspec
Oth viral dis-delivered
Oth viral dis-del w p/p
Oth viral dis-antepartum
Oth viral dis-postpartum
Inf dis in preg NEC-unsp
Infect dis NEC-delivered
Infect dis NEC-del w p/p
Infect dis NEC-antepart
Infect dis NEC-postpart
Infect in preg NOS-unsp
October 2009
64791
64792
64793
64794
64800
64801
64802
64803
64804
64810
64811
64812
64813
64814
64820
64821
64822
64823
64824
64830
64831
64832
64833
64834
64840
64841
64842
64843
64844
64850
64851
64852
64853
64854
64860
64861
64862
64863
64864
64870
64871
64872
64873
64874
64880
64881
64882
64883
64884
64890
64891
64892
64893
64894
64900
64901
64902
64903
64904
64910
64911
64912
64913
64914
64920
64921
64922
64923
Infect NOS-delivered
Infect NOS-deliver w p/p
Infect NOS-antepartum
Infect NOS-postpartum
Diabetes in preg-unspec
Diabetes-delivered
Diabetes-delivered w p/p
Diabetes-antepartum
Diabetes-postpartum
Thyroid dysfun preg-unsp
Thyroid dysfunc-deliver
Thyroid dysfun-del w p/p
Thyroid dysfunc-antepart
Thyroid dysfunc-postpart
Anemia in preg-unspec
Anemia-delivered
Anemia-delivered w p/p
Anemia-antepartum
Anemia-postpartum
Drug depend preg-unspec
Drug dependence-deliver
Drug dependen-del w p/p
Drug dependence-antepart
Drug dependence-postpart
Mental dis preg-unspec
Mental disorder-deliver
Mental dis-deliv w p/p
Mental disorder-antepart
Mental disorder-postpart
Congen CV dis preg-unsp
Congen CV dis-delivered
Congen CV dis-del w p/p
Congen CV dis-antepartum
Congen CV dis-postpartum
CV dis NEC preg-unspec
CV dis NEC preg-deliver
CV dis NEC-deliver w p/p
CV dis NEC-antepartum
CV dis NEC-postpartum
Bone disord in preg-unsp
Bone disorder-delivered
Bone disorder-del w p/p
Bone disorder-antepartum
Bone disorder-postpartum
Abn glucose in preg-unsp
Abn glucose toler-deliv
Abn glucose-deliv w p/p
Abn glucose-antepartum
Abn glucose-postpartum
Oth curr cond preg-unsp
Oth curr cond-delivered
Oth curr cond-del w p/p
Oth curr cond-antepartum
Oth curr cond-postpartum
Tobacco use disord-unsp
Tobacco use disor-delliv
Tobacco use dis-del-p/p
Tobacco use dis-antepart
Tobacco use dis-postpart
Obesity-unspecified
Obesity-delivered
Obesity-delivered w p/p
Obesity-antepartum
Obesity-postpartum
Bariatric surg stat-unsp
Bariatric surg stat-del
Bariatric surg-del w p/p
Bariatrc surg stat-antep
Edit code lists 1.11
Maternity diagnoses (age 12 through 55)
64924
64930
64931
64932
64933
64934
64940
64941
64942
64943
64944
64950
64951
64953
64960
64961
64962
64963
64964
64970
64971
64973
650
65100
65101
65103
65110
65111
65113
65120
65121
65123
65130
65131
65133
65140
65141
65143
65150
65151
65153
65160
65161
65163
65170
65171
65173
65180
65181
65183
65190
65191
65193
65200
65201
65203
65210
65211
65213
65220
65221
65223
65230
65231
65233
65240
65241
65243
Bariatrc surg stat w p/p
Coagulation def-unspec
Coagulation def-deliv
Coagulatn def-del w p/p
Coagulation def-antepart
Coagulation def-postpart
Epilepsy-unspecified
Epilepsy-delivered
Epilepsy-delivered w p/p
Epilepsy-antepartum
Epilepsy-postpartum
Spotting-unspecified
Spotting-delivered
Spotting-antepartum
Uterine size descrp-unsp
Uterine size descrep-del
Uterine size-del w p/p
Uterine size des-antepar
Uterine size descrep-p/p
Cervical shortening-unsp
Cervical shortening-del
Cervical shortening-ante
Normal delivery
Twin pregnancy-unspec
Twin pregnancy-delivered
Twin pregnancy-antepart
Triplet pregnancy-unspec
Triplet pregnancy-deliv
Triplet preg-antepartum
Quadruplet preg-unspec
Quadruplet preg-deliver
Quadruplet preg-antepart
Twins w fetal loss-unsp
Twins w fetal loss-del
Twins w fetal loss-ante
Triplets w fet loss-unsp
Triplets w fet loss-del
Triplets w fet loss-ante
Quads w fetal loss-unsp
Quads w fetal loss-del
Quads w fetal loss-ante
Mult ges w fet loss-unsp
Mult ges w fet loss-del
Mult ges w fet loss-ante
Mul gest-fet reduct unsp
Mult gest-fet reduct del
Mul gest-fet reduct ante
Multi gestat NEC-unspec
Multi gestat NEC-deliver
Multi gest NEC-antepart
Multi gestat NOS-unspec
Mult gestation NOS-deliv
Multi gest NOS-antepart
Unstable lie-unspecified
Unstable lie-delivered
Unstable lie-antepartum
Cephalic vers NOS-unspec
Cephalic vers NOS-deliv
Cephal vers NOS-antepart
Breech presentat-unspec
Breech presentat-deliver
Breech present-antepart
Transv/obliq lie-unspec
Transver/obliq lie-deliv
Transv/obliq lie-antepar
Face/brow present-unspec
Face/brow present-deliv
Face/brow pres-antepart
1.12 Definitions of Medicare Code Edits
65250
65251
65253
65260
65261
65263
65270
65271
65273
65280
65281
65283
65290
65291
65293
65300
65301
65303
65310
65311
65313
65320
65321
65323
65330
65331
65333
65340
65341
65343
65350
65351
65353
65360
65361
65363
65370
65371
65373
65380
65381
65383
65390
65391
65393
65400
65401
65402
65403
65404
65410
65411
65412
65413
65414
65420
65421
65423
65430
65431
65432
65433
65434
65440
65441
65442
65443
65444
High head at term-unspec
High head at term-deliv
High head term-antepart
Mult gest malpresen-unsp
Mult gest malpres-deliv
Mult ges malpres-antepar
Prolapsed arm-unspec
Prolapsed arm-delivered
Prolapsed arm-antepart
Malposition NEC-unspec
Malposition NEC-deliver
Malposition NEC-antepart
Malposition NOS-unspec
Malposition NOS-deliver
Malposition NOS-antepart
Pelvic deform NOS-unspec
Pelvic deform NOS-deliv
Pelv deform NOS-antepart
Contract pelv NOS-unspec
Contract pelv NOS-deliv
Contrac pelv NOS-antepar
Inlet contraction-unspec
Inlet contraction-deliv
Inlet contract-antepart
Outlet contraction-unsp
Outlet contraction-deliv
Outlet contract-antepart
Fetopelv disprop-unspec
Fetopelv dispropor-deliv
Fetopel disprop-antepart
Fetal disprop NOS-unspec
Fetal disprop NOS-deliv
Fetal dispro NOS-antepar
Hydrocephal fetus-unspec
Hydroceph fetus-deliver
Hydroceph fetus-antepart
Oth abn fet disprop-unsp
Oth abn fet dispro-deliv
Oth abn fet dispro-antep
Disproportion NEC-unspec
Disproportion NEC-deliv
Dispropor NEC-antepartum
Disproportion NOS-unspec
Disproportion NOS-deliv
Dispropor NOS-antepartum
Cong abn uter preg-unsp
Congen abn uterus-deliv
Cong abn uter-del w p/p
Congen abn uter-antepart
Congen abn uter-postpart
Uter tumor in preg-unsp
Uterine tumor-delivered
Uterine tumor-del w p/p
Uterine tumor-antepartum
Uterine tumor-postpartum
Prev c-delivery unspec
Prev c-delivery-delivrd
Prev c-delivery-antepart
Retrovert uterus-unspec
Retrovert uterus-deliver
Retrovert uter-del w p/p
Retrovert uter-antepart
Retrovert uter-postpart
Abn grav uterus NEC-unsp
Abn uterus NEC-delivered
Abn uterus NEC-del w p/p
Abn uterus NEC-antepart
Abn uterus NEC-postpart
October 2009
Maternity diagnoses (age 12 through 55)
65450
65451
65452
65453
65454
65460
65461
65462
65463
65464
65470
65471
65472
65473
65474
65480
65481
65482
65483
65484
65490
65491
65492
65493
65494
65500
65501
65503
65510
65511
65513
65520
65521
65523
65530
65531
65533
65540
65541
65543
65550
65551
65553
65560
65561
65563
65570
65571
65573
65580
65581
65583
65590
65591
65593
65600
65601
65603
65610
65611
65613
65620
65621
65623
65630
65631
65633
65640
Cerv incompet preg-unsp
Cervical incompet-deliv
Cerv incompet-del w p/p
Cerv incompet-antepartum
Cerv incompet-postpartum
Abn cervix NEC preg-unsp
Abn cervix NEC-delivered
Abn cervix NEC-del w p/p
Abn cervix NEC-antepart
Abn cervix NEC-postpart
Abn vagina in preg-unsp
Abnorm vagina-delivered
Abnorm vagina-del w p/p
Abnorm vagina-antepartum
Abnorm vagina-postpartum
Abn vulva in preg-unspec
Abnormal vulva-delivered
Abnormal vulva-del w p/p
Abnormal vulva-antepart
Abnormal vulva-postpart
Abn pel NEC in preg-unsp
Abn pelv org NEC-deliver
Abn pelv NEC-deliv w p/p
Abn pelv org NEC-antepar
Abn pelv org NEC-postpar
Fetal cns malform-unspec
Fetal cns malform-deliv
Fetal cns malfor-antepar
Fetal chromos abn-unspec
Fetal chromoso abn-deliv
Fet chromo abn-antepart
Famil heredit dis-unspec
Famil heredit dis-deliv
Famil hered dis-antepart
Fet damg d/t virus-unsp
Fet damg d/t virus-deliv
Fet damg d/t virus-antep
Fet damg d/t dis-unspec
Fet damg d/t dis-deliver
Fet damg d/t dis-antepar
Fetal damg d/t drug-unsp
Fet damag d/t drug-deliv
Fet damg d/t drug-antepa
Radiat fetal damag-unsp
Radiat fetal damag-deliv
Radiat fet damag-antepar
Decrease fetl movmt unsp
Decrease fetal movmt del
Dec fetal movmt antepart
Fetal abnorm NEC-unspec
Fetal abnorm NEC-deliver
Fetal abnorm NEC-antepar
Fetal abnorm NOS-unspec
Fetal abnorm NOS-deliver
Fetal abnorm NOS-antepar
Fetal-maternal hem-unsp
Fetal-maternal hem-deliv
Fetal-matern hem-antepar
Rh isoimmunization-unsp
Rh isoimmunizat-deliver
Rh isoimmunizat-antepart
Abo isoimmunization-unsp
Abo isoimmunizat-deliver
Abo isoimmunizat-antepar
Fetal distress-unspec
Fetal distress-delivered
Fetal distress-antepart
Intrauterine death-unsp
October 2009
65641
65643
65650
65651
65653
65660
65661
65663
65670
65671
65673
65680
65681
65683
65690
65691
65693
65700
65701
65703
65800
65801
65803
65810
65811
65813
65820
65821
65823
65830
65831
65833
65840
65841
65843
65880
65881
65883
65890
65891
65893
65900
65901
65903
65910
65911
65913
65920
65921
65923
65930
65931
65933
65940
65941
65943
65950
65951
65953
65960
65961
65963
65970
65971
65973
65980
65981
65983
Intrauter death-deliver
Intrauter death-antepart
Poor fetal growth-unspec
Poor fetal growth-deliv
Poor fetal grth-antepart
Excess fetal grth-unspec
Excess fetal grth-deliv
Excess fet grth-antepart
Oth placent cond-unspec
Oth placent cond-deliver
Oth placent cond-antepar
Fet/plac prob NEC-unspec
Fet/plac prob NEC-deliv
Fet/plac prob NEC-antepa
Fet/plac prob NOS-unspec
Fet/plac prob NOS-deliv
Fet/plac prob NOS-antepa
Polyhydramnios-unspec
Polyhydramnios-delivered
Polyhydramnios-antepart
Oligohydramnios-unspec
Oligohydramnios-deliver
Oligohydramnios-antepar
Prem rupt membran-unspec
Prem rupt membran-deliv
Prem rupt memb-antepart
Prolong rupt memb-unspec
Prolong rupt memb-deliv
Prolong rup memb-antepar
Artific rupt membr-unsp
Artific rupt membr-deliv
Artif rupt memb-antepart
Amniotic infection-unsp
Amniotic infection-deliv
Amniotic infect-antepart
Amniotic prob NEC-unspec
Amniotic prob NEC-deliv
Amnion prob NEC-antepart
Amniotic prob NOS-unspec
Amniotic prob NOS-deliv
Amnion prob NOS-antepart
Fail mechan induct-unsp
Fail mech induct-deliver
Fail mech induct-antepar
Fail induction NOS-unsp
Fail induction NOS-deliv
Fail induct NOS-antepart
Pyrexia in labor-unspec
Pyrexia in labor-deliver
Pyrexia in labor-antepar
Septicemia in labor-unsp
Septicem in labor-deliv
Septicem in labor-antepa
Grand multiparity-unspec
Grand multiparity-deliv
Grand multiparity-antepa
Elderly primigravid-unsp
Elderly primigravida-del
Elder primigravid-antepa
Elderly multigravida-uns
Elderly multigravida-del
Elderly multigravd-antep
Abn ftl hrt rate/rhy-uns
Abn ftl hrt rate/rhy-del
Abn ftl hrt rate/rhy-ant
Complic labor NEC-unsp
Complic labor NEC-deliv
Compl labor NEC-antepart
Edit code lists 1.13
Maternity diagnoses (age 12 through 55)
65990
65991
65993
66000
66001
66003
66010
66011
66013
66020
66021
66023
66030
66031
66033
66040
66041
66043
66050
66051
66053
66060
66061
66063
66070
66071
66073
66080
66081
66083
66090
66091
66093
66100
66101
66103
66110
66111
66113
66120
66121
66123
66130
66131
66133
66140
66141
66143
66190
66191
66193
66200
66201
66203
66210
66211
66213
66220
66221
66223
66230
66231
66233
66300
66301
66303
66310
66311
Complic labor NOS-unsp
Complic labor NOS-deliv
Compl labor NOS-antepart
Obstruct/fet malpos-unsp
Obstruc/fet malpos-deliv
Obstruc/fet malpos-antep
Bony pelv obstruc-unspec
Bony pelv obstruct-deliv
Bony pelv obstruc-antepa
Abn pelv tiss obstr-unsp
Abn pelv tis obstr-deliv
Abn pelv tis obstr-antep
Persist occipitpost-unsp
Persist occiptpost-deliv
Persist occiptpost-antep
Shoulder dystocia-unspec
Shoulder dystocia-deliv
Shoulder dystocia-antepa
Locked twins-unspecified
Locked twins-delivered
Locked twins-antepartum
Fail trial lab NOS-unsp
Fail trial lab NOS-deliv
Fail trial lab NOS-antep
Failed forcep NOS-unspec
Failed forceps NOS-deliv
Fail forceps NOS-antepar
Obstruc labor NEC-unspec
Obstruct labor NEC-deliv
Obstruc labor NEC-antepa
Obstruc labor NOS-unspec
Obstruct labor NOS-deliv
Obstruc labor NOS-antepa
Prim uterine inert-unsp
Prim uterine inert-deliv
Prim uter inert-antepart
Sec uterine inert-unspec
Sec uterine inert-deliv
Sec uterine inert-antepa
Uterine inertia NEC-unsp
Uterine inert NEC-deliv
Uterine inert NEC-antepa
Precipitate labor-unspec
Precipitate labor-deliv
Precipitate labor-antepa
Uter dystocia NOS-unspec
Uter dystocia NOS-deliv
Uter dystocia NOS-antepa
Abnormal labor NOS-unsp
Abnormal labor NOS-deliv
Abnorm labor NOS-antepar
Prolonged 1st stage-unsp
Prolong 1st stage-deliv
Prolong 1st stage-antepa
Prolonged labor NOS-unsp
Prolong labor NOS-deliv
Prolong labor NOS-antepa
Prolonged 2nd stage-unsp
Prolong 2nd stage-deliv
Prolong 2nd stage-antepa
Delay del 2nd twin-unsp
Delay del 2nd twin-deliv
Delay del 2 twin-antepar
Cord prolapse-unspec
Cord prolapse-delivered
Cord prolapse-antepartum
Cord around neck-unspec
Cord around neck-deliver
1.14 Definitions of Medicare Code Edits
66313
66320
66321
66323
66330
66331
66333
66340
66341
66343
66350
66351
66353
66360
66361
66363
66380
66381
66383
66390
66391
66393
66400
66401
66404
66410
66411
66414
66420
66421
66424
66430
66431
66434
66440
66441
66444
66450
66451
66454
66460
66461
66464
66480
66481
66484
66490
66491
66494
66500
66501
66503
66510
66511
66520
66522
66524
66530
66531
66534
66540
66541
66544
66550
66551
66554
66560
66561
Cord around neck-antepar
Cord compress NEC-unspec
Cord compress NEC-deliv
Cord compres NEC-antepar
Cord entangle NEC-unspec
Cord entangle NEC-deliv
Cord entangl NEC-antepar
Short cord-unspecified
Short cord-delivered
Short cord-antepartum
Vasa previa-unspecified
Vasa previa-delivered
Vasa previa-antepartum
Vasc lesion cord-unspec
Vasc lesion cord-deliver
Vasc lesion cord-antepar
Cord complicat NEC-unsp
Cord complicat NEC-deliv
Cord compl NEC-antepart
Cord complicat NOS-unsp
Cord complicat NOS-deliv
Cord compl NOS-antepart
Del w 1 deg lacerat-unsp
Del w 1 deg lacerat-del
Del w 1 deg lac-postpart
Del w 2 deg lacerat-unsp
Del w 2 deg lacerat-del
Del w 2 deg lac-postpart
Del w 3 deg lacerat-unsp
Del w 3 deg lacerat-del
Del w 3 deg lac-postpart
Del w 4 deg lacerat-unsp
Del w 4 deg lacerat-del
Del w 4 deg lac-postpart
Ob perineal lac NOS-unsp
Ob perineal lac NOS-del
Perineal lac NOS-postpar
Ob perineal hematom-unsp
Ob perineal hematoma-del
Perin hematoma-postpart
Anal sphincter tear NOS
Anal sphincter tear-del
Anal sphinctr tear w p/p
Ob perin traum NEC-unsp
Ob perineal trau NEC-del
Perin traum NEC-postpart
Ob perin traum NOS-unsp
Ob perineal trau NOS-del
Perin traum NOS-postpart
Prelabor rupt uter-unsp
Prelabor rupt uterus-del
Prelab rupt uter-antepar
Rupture uterus NOS-unsp
Rupture uterus NOS-deliv
Inversion of uterus-unsp
Invers uterus-del w p/p
Invers uterus-postpart
Lacerat of cervix-unspec
Lacerat of cervix-deliv
Lacer of cervix-postpart
High vaginal lacer-unsp
High vaginal lacer-deliv
High vaginal lac-postpar
Ob inj pelv org NEC-unsp
Ob inj pelv org NEC-del
Inj pelv org NEC-postpar
Damage to pelvic jt-unsp
Damage to pelvic jt-del
October 2009
Maternity diagnoses (age 12 through 55)
67153
67154
67180
67181
67182
67183
67184
67190
67191
67192
67193
67194
67200
67202
67204
67300
67301
67302
67303
67304
67310
67311
67312
67313
67314
67320
67321
67322
67323
67324
67330
67331
67332
67333
67334
67380
67381
67382
67383
67384
67400
67401
67402
67403
67404
67410
67412
67414
67420
67422
67424
67430
67432
67434
67440
67442
67444
67450
67451
67452
67453
67454
67480
67482
67484
67490
67492
67494
Thrombosis NEC-antepart
Thrombosis NEC-postpart
Ven compl preg NEC-unsp
Venous compl NEC-deliver
Ven comp NEC-deliv w p/p
Venous compl NEC-antepar
Venous compl NEC-postpar
Ven compl preg NOS-unsp
Venous compl NOS-deliver
Ven comp NOS-deliv w p/p
Venous compl NOS-antepar
Venous compl NOS-postpar
Puerperal pyrexia-unspec
Puerp pyrexia-del w p/p
Puerp pyrexia-postpartum
Ob air embolism-unspec
Ob air embolism-deliver
Ob air embol-deliv w p/p
Ob air embolism-antepart
Ob air embolism-postpart
Amniotic embolism-unspec
Amniotic embolism-deliv
Amniot embol-deliv w p/p
Amniotic embol-antepart
Amniotic embol-postpart
Ob pulm embol NOS-unspec
Pulm embol NOS-delivered
Pulm embol NOS-del w p/p
Pulm embol NOS-antepart
Pulm embol NOS-postpart
Ob pyemic embol-unspec
Ob pyemic embol-deliver
Ob pyem embol-del w p/p
Ob pyemic embol-antepart
Ob pyemic embol-postpart
Ob pulmon embol NEC-unsp
Pulmon embol NEC-deliver
Pulm embol NEC-del w p/p
Pulmon embol NEC-antepar
Pulmon embol NEC-postpar
Puerp cerebvasc dis-unsp
Puerp cerebvas dis-deliv
Cerebvas dis-deliv w p/p
Cerebrovasc dis-antepart
Cerebrovasc dis-postpart
Disrupt c-sect wnd-unsp
Disrupt c-sect-del w p/p
Disrupt c-sect-postpart
Disrupt perineum-unspec
Disrupt perin-del w p/p
Disrupt perineum-postpar
Ob surg compl NEC-unspec
Ob surg compl-del w p/p
Ob surg comp NEC-postpar
Placental polyp-unspec
Placent polyp-del w p/p
Placental polyp-postpart
Peripart cardiomy-unspec
Peripartum cardiomy-del
Peripart card del w p/p
Peripartum card-antepart
Peripartum card-postpart
Puerp compl NEC-unspec
Puerp comp NEC-del w p/p
Puerp compl NEC-postpart
Puerp compl NOS-unspec
Puerp comp NOS-del w p/p
Puerp compl NOS-postpart
October 2009
67500
67501
67502
67503
67504
67510
67511
67512
67513
67514
67520
67521
67522
67523
67524
67580
67581
67582
67583
67584
67590
67591
67592
67593
67594
67600
67601
67602
67603
67604
67610
67611
67612
67613
67614
67620
67621
67622
67623
67624
67630
67631
67632
67633
67634
67640
67641
67642
67643
67644
67650
67651
67652
67653
67654
67660
67661
67662
67663
67664
67680
67681
67682
67683
67684
67690
67691
67692
Infect nipple preg-unsp
Infect nipple-delivered
Infect nipple-del w p/p
Infect nipple-antepartum
Infect nipple-postpartum
Breast abscess preg-unsp
Breast abscess-delivered
Breast abscess-del w p/p
Breast abscess-antepart
Breast abscess-postpart
Mastitis in preg-unspec
Mastitis-delivered
Mastitis-deliv w p/p
Mastitis-antepartum
Mastitis-postpartum
Breast inf preg NEC-unsp
Breast infect NEC-deliv
Breast inf NEC-del w p/p
Breast inf NEC-antepart
Breast inf NEC-postpart
Breast inf preg NOS-unsp
Breast infect NOS-deliv
Breast inf NOS-del w p/p
Breast inf NOS-antepart
Breast inf NOS-postpart
Retract nipple preg-unsp
Retracted nipple-deliver
Retract nipple-del w p/p
Retract nipple-antepart
Retract nipple-postpart
Cracked nipple preg-unsp
Cracked nipple-delivered
Cracked nipple-del w p/p
Cracked nipple-antepart
Cracked nipple-postpart
Breast engorge-unspec
Breast engorge-delivered
Breast engorge-del w p/p
Breast engorge-antepart
Breast engorge-postpart
Breast dis preg NEC-unsp
Breast dis NEC-delivered
Breast dis NEC-del w p/p
Breast dis NEC-antepart
Breast dis NEC-postpart
Lactation fail-unspec
Lactation fail-delivered
Lactation fail-del w p/p
Lactation fail-antepart
Lactation fail-postpart
Suppr lactation-unspec
Suppr lactation-deliver
Suppr lactat-del w p/p
Suppr lactation-antepar
Suppr lactation-postpart
Galactorrhea preg-unspec
Galactorrhea-delivered
Galactorrhea-del w p/p
Galactorrhea-antepartum
Galactorrhea-postpartum
Lactation dis NEC-unspec
Lactation dis NEC-deliv
Lactat dis NEC-del w p/p
Lactat dis NEC-antepart
Lactat dis NEC-postpart
Lactation dis NOS-unspec
Lactation dis NOS-deliv
Lactat dis NOS-del w p/p
Edit code lists 1.15
Maternity diagnoses (age 12 through 55)
66564
66570
66571
66572
66574
66580
66581
66582
66583
66584
66590
66591
66592
66593
66594
66600
66602
66604
66610
66612
66614
66620
66622
66624
66630
66632
66634
66700
66702
66704
66710
66712
66714
66800
66801
66802
66803
66804
66810
66811
66812
66813
66814
66820
66821
66822
66823
66824
66880
66881
66882
66883
66884
66890
66891
66892
66893
66894
66900
66901
66902
66903
66904
66910
66911
66912
66913
66914
Damage pelvic jt-postpar
Ob pelvic hematoma-unsp
Ob pelvic hematoma-deliv
Pelvic hematom-del w pp
Pelvic hematoma-postpart
Ob trauma NEC-unspec
Ob trauma NEC-delivered
Ob trauma NEC-del w p/p
Ob trauma NEC-antepartum
Ob trauma NEC-postpartum
Ob trauma NOS-unspec
Ob trauma NOS-delivered
Ob trauma NOS-del w p/p
Ob trauma NOS-antepartum
Ob trauma NOS-postpartum
Third-stage hem-unspec
Thrd-stage hem-del w p/p
Third-stage hem-postpart
Postpartum hem NEC-unsp
Postpa hem NEC-del w p/p
Postpart hem NEC-postpar
Delay p/part hem-unspec
Delay p/p hem-del w p/p
Delay p/part hem-postpar
Postpart coagul def-unsp
P/p coag def-del w p/p
Postpart coag def-postpa
Retain placenta NOS-unsp
Retnd plac NOS-del w p/p
Retain plac NOS-postpart
Retain prod concept-unsp
Ret prod conc-del w p/p
Ret prod concept-postpar
Pulm compl in del-unspec
Pulm compl in del-deliv
Pulm complic-del w p/p
Pulm complicat-antepart
Pulm complicat-postpart
Heart compl in del-unsp
Heart compl in del-deliv
Heart compl-del w p/p
Heart complic-antepart
Heart complic-postpart
Cns compl labor/del-unsp
Cns compl lab/del-deliv
Cns complic-del w p/p
Cns compl in del-antepar
Cns compl in del-postpar
Anesth comp del NEC-unsp
Anesth compl NEC-deliver
Anesth compl NEC-del p/p
Anesth compl antepartum
Anesth compl-postpartum
Anesth comp del NOS-unsp
Anesth compl NOS-deliver
Anesth compl NOS-del p/p
Anesth compl-antepartum
Anesth compl-postpartum
Maternal distress-unspec
Maternal distress-deliv
Matern distres-del w p/p
Matern distress-antepar
Matern distress-postpart
Obstetric shock-unspec
Obstetric shock-deliver
Obstet shock-deliv w p/p
Obstetric shock-antepar
Obstetric shock-postpart
1.16 Definitions of Medicare Code Edits
66920
66921
66922
66923
66924
66930
66932
66934
66940
66941
66942
66943
66944
66950
66951
66960
66961
66970
66971
66980
66981
66982
66983
66984
66990
66991
66992
66993
66994
67000
67002
67004
67010
67012
67014
67020
67022
67024
67030
67032
67034
67080
67082
67084
67100
67101
67102
67103
67104
67110
67111
67112
67113
67114
67120
67121
67122
67123
67124
67130
67131
67133
67140
67142
67144
67150
67151
67152
Matern hypotens syn-unsp
Matern hypoten syn-deliv
Matern hypoten-del w p/p
Matern hypotens-antepar
Matern hypotens-postpart
Ac kidny fail w del-unsp
Ac kidney fail-del w p/p
Ac kidney fail-postpart
Oth ob surg compl-unspec
Oth ob compl-delivered
Oth ob compl-deliv w p/p
Complc ob surg anteprtm
Oth ob surg compl-postpa
Forcep deliv NOS-unspec
Forcep deliv NOS-deliver
Breech extr NOS-unspec
Breech extr NOS-deliver
Cesarean deliv NOS-unsp
Cesarean delivery NOS
Compl lab/deliv NEC-unsp
Comp lab/deliv NEC-deliv
Compl del NEC-del w p/p
Compl deliv NEC-antepar
Compl deliv NEC-postpart
Compl lab/deliv NOS-unsp
Comp lab/deliv NOS-deliv
Compl del NOS-del w p/p
Compl deliv NOS-antepar
Compl deliv NOS-postpart
Maj puerp inf NOS-unsp
Maj puer inf NOS-del p/p
Major puerp inf NOS-p/p
Puerp endometritis-unsp
Puerp endomet del w p/p
Puerp endomet-postpart
Puerperal sepsis-unsp
Puerprl sepsis-del w p/p
Puerperl sepsis-postpart
Puerp septc thromb-unsp
Prp sptc thrmb-del w p/p
Prp septc thrmb-postpart
Maj prp infec NEC-unspec
Maj prp inf NEC-dl w p/p
Maj puerp infec NEC-p/p
Varic vein leg preg-unsp
Varicose vein leg-deliv
Varic vein leg-del w p/p
Varic vein leg-antepart
Varic vein leg-postpart
Varic vulva preg-unspec
Varicose vulva-delivered
Varicose vulva-del w p/p
Varicose vulva-antepart
Varicose vulva-postpart
Thrombophleb preg-unspec
Thrombophlebitis-deliver
Thrombophleb-deliv w p/p
Thrombophlebit-antepart
Thrombophlebit-postpart
Deep thromb antepar-unsp
Deep throm antepar-deliv
Deep vein thromb-antepar
Deep thromb postpar-unsp
Thromb postpar-del w p/p
Deep vein thromb-postpar
Thrombosis NEC preg-unsp
Thrombosis NEC-delivered
Thromb NEC-deliv w p/p
October 2009
Maternity diagnoses (age 12 through 55)
67693
67694
67800
67801
67803
67810
67811
67813
67900
67901
67902
67903
67904
67910
67911
67912
67913
67914
7923
7965
V230
V231
V232
V233
V2341
V2349
V235
V237
V2381
V2382
V2383
V2384
V2385
V2386
V2389
V239
V240
V270
V271
V272
V273
V274
V275
V276
V277
V279
V280
V281
V282
V286
V2881
V2882
V2889
V616
V617
V7242
V8901
V8902
V8903
V8904
V8905
V8909
Lactat dis NOS-antepart
Lactat dis NOS-postpart
Fetal hematologic-unspec
Fetal hematologic-deliv
Fetal hematologic-ante
Fetal conjoin twins-unsp
Fetal conjoin twins-del
Fetal conjoin twins-ante
Mat comp in utero-unsp
Mat comp in utero-del
Mat comp in utro-del-p/p
Mat comp in utero-ante
Mat comp in utero-p/p
Fetal comp in utero-unsp
Fetal comp in utero-del
Ftl cmp in utro-del-p/p
Fetal comp in utero-ante
Fetal comp in utero-p/p
Abn find-amniotic fluid
Abn find antenatl screen
Preg w hx of infertility
Preg w hx-trophoblas dis
Preg w hx of abortion
Grand multiparity
Preg w hx pre-term labor
Preg w poor obs hx NEC
Preg w poor reproduct hx
Insufficnt prenatal care
Suprv elderly primigrav
Suprv elderly multigrav
Suprv young primigravida
Suprv young multigravida
Pregnt-assist repro tech
Preg-hx in utro prev prg
Suprv high-risk preg NEC
Suprv high-risk preg NOS
Postpart care after del
Deliver-single liveborn
Deliver-single stillborn
Deliver-twins, both live
Del-twins, 1 nb, 1 sb
Deliver-twins, both sb
Del-mult birth, all live
Del-mult brth, some live
Del-mult birth, all sb
Outcome of delivery NOS
Screening-chromosom anom
Screen-alphafetoprotein
Screen by amniocent NEC
Antenatal screen strep b
Scrn fetal anatmc survey
Scrn risk preterm labor
Antenatal screening NEC
Illegitimate pregnancy
Unwanted pregnancy NEC
Pregnancy test-positive
Sus amntc cav/mem nt fnd
Sus placentl prob nt fnd
Sus fetal anomaly nt fnd
Sus fetal growth not fnd
Sus cervcl shortn nt fnd
Oth sus mat/ftl nt fnd
October 2009
Edit code lists 1.17
Adult diagnoses (age greater than 14)
25631
2900
29010
29011
29012
29013
29020
29021
2903
29040
29041
29042
29043
2909
33520
36610
36611
36612
36613
36614
36615
36616
36617
36618
36619
37401
37411
41400
41401
41402
41403
41404
41405
41407
4143
42971
42979
4370
4400
4401
44020
44021
44022
44023
44029
44030
44031
44032
4408
4409
4540
4541
4542
4549
4570
500
501
5710
5711
5712
5713
60000
60001
60010
60011
Premature menopause
Senile dementia uncomp
Presenile dementia
Presenile delirium
Presenile delusion
Presenile depression
Senile delusion
Senile depressive
Senile delirium
Vascular dementia,uncomp
Vasc dementia w delirium
Vasc dementia w delusion
Vasc dementia w depressn
Senile psychot cond NOS
Amyotrophic sclerosis
Senile cataract NOS
Pseudoexfol lens capsule
Incipient cataract
Ant subcaps senile catar
Post subcap senile catar
Cortical senile cataract
Senile nuclear cataract
Mature cataract
Hypermature cataract
Senile cataract NEC
Senile entropion
Senile ectropion
Cor ath unsp vsl ntv/gft
Crnry athrscl natve vssl
Crn ath atlg vn bps grft
Crn ath nonatlg blg grft
Cor ath artry bypas grft
Cor ath bypass graft NOS
Cor ath bps graft tp hrt
Cor ath d/t lpd rch plaq
Acq cardiac septl defect
Other sequelae of MI NEC
Cerebral atherosclerosis
Aortic atherosclerosis
Renal artery atheroscler
Athscl extrm ntv art NOS
Ath ext ntv at w claudct
Ath ext ntv at w rst pn
Ath ext ntv art ulcrtion
Athrsc extrm ntv art oth
Athscl extrm bps gft NOS
Ath ext autologs bps gft
Ath ext nonautlg bps gft
Atherosclerosis NEC
Atherosclerosis NOS
Leg varicosity w ulcer
Leg varicosity w inflam
Varicos leg ulcer/inflam
Asympt varicose veins
Postmastect lymphedema
Coal workers' pneumocon
Asbestosis
Alcoholic fatty liver
Ac alcoholic hepatitis
Alcohol cirrhosis liver
Alcohol liver damage NOS
BPH w/o urinary obs/LUTS
BPH w urinary obs/LUTS
Nod prostate w/o ur obst
Nod prostate w ur obst
1.18 Definitions of Medicare Code Edits
60020
60021
6003
60090
60091
6010
6011
6012
6013
6014
6018
6019
6020
6021
6022
6028
6029
6060
6061
6068
6069
60784
6101
61181
61182
61183
6120
6121
7286
7837
79093
79981
99580
99581
99582
99583
99584
99585
V2385
V4981
V510
V6221
V6222
V6229
V7101
V850
V851
V8521
V8522
V8523
V8524
V8525
V8530
V8531
V8532
V8533
V8534
V8535
V8536
V8537
V8538
V8539
V854
BPH loc w/o ur obs/LUTS
BPH loc w urin obs/LUTS
Cyst of prostate
BPH NOS w/o ur obs/LUTS
BPH NOS w ur obs/LUTS
Acute prostatitis
Chronic prostatitis
Abscess of prostate
Prostatocystitis
Prostatitis in oth dis
Prostatic inflam dis NEC
Prostatitis NOS
Calculus of prostate
Prostatic congest/hemorr
Atrophy of prostate
Prostatic disorders NEC
Prostatic disorder NOS
Azoospermia
Oligospermia
Male infertility NEC
Male infertility NOS
Impotence, organic orign
Diffus cystic mastopathy
Ptosis of breast
Hypoplasia of breast
Capslr contrctr brst imp
Deformity reconst breast
Disproportn reconst brst
Contracted palmar fascia
Failure to thrive-adult
Elvtd prstate spcf antgn
Decreased libido
Adult maltreatment NOS
Adult physical abuse
Adult emotnl/psych abuse
Adult sexual abuse
Adult neglect-nutrition
Oth adult abuse/neglect
Pregnt-assist repro tech
Asympt postmeno status
Brst reconst fol mastect
Hx military deployment
Hx retrn military deploy
Occupationl circumst NEC
Obsv-adult antisoc behav
BMI less than 19,adult
BMI between 19-24,adult
BMI 25.0-25.9,adult
BMI 26.0-26.9,adult
BMI 27.0-27.9,adult
BMI 28.0-28.9,adult
BMI 29.0-29.9,adult
BMI 30.0-30.9,adult
BMI 31.0-31.9,adult
BMI 32.0-32.9,adult
BMI 33.0-33.9,adult
BMI 34.0-34.9,adult
BMI 35.0-35.9,adult
BMI 36.0-36.9,adult
BMI 37.0-37.9,adult
BMI 38.0-38.9,adult
BMI 39.0-39.9,adult
BMI 40 and over,adult
October 2009
5. Sex conflict
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 pages contain lists of male and female related
ICD-9-CM diagnosis and procedure codes with corresponding
English descriptions.
October 2009
Edit code lists 1.19
Diagnoses allowed for females only
01660
01661
01662
01663
01664
01665
01666
01670
01671
01672
01673
01674
01675
01676
05411
05412
09815
09816
09817
09835
09836
09837
1121
13101
1740
1741
1742
1743
1744
1745
1746
1748
1749
179
1800
1801
1808
1809
181
1820
1821
1828
1830
1832
1833
1834
1835
1838
1839
1840
1841
1842
1843
1844
1848
1849
1986
2180
2181
2182
2189
2190
2191
2198
2199
TB ovary & tube-unspec
TB ovary & tube-no exam
TB ovary/tube-exam unkn
TB ovary & tube-micro dx
TB ovary & tube-cult dx
TB ovary & tube-histo dx
TB ovary & tube-oth test
TB female gen NEC-unspec
TB fem gen NEC-no exam
TB fem gen NEC-exam unkn
TB fem gen NEC-micro dx
TB fem gen NEC-cult dx
TB fem gen NEC-histo dx
TB fem gen NEC-oth test
Herpetic vulvovaginitis
Herpetic ulcer of vulva
Gc cervicitis (acute)
Gc endometritis (acute)
Acute gc salpingitis
Gc cervicitis, chronic
Gc endometritis, chronic
Gc salpingitis (chronic)
Candidal vulvovaginitis
Trichomonal vaginitis
Malig neo nipple
Mal neo breast-central
Mal neo breast up-inner
Mal neo breast low-inner
Mal neo breast up-outer
Mal neo breast low-outer
Mal neo breast-axillary
Malign neopl breast NEC
Malign neopl breast NOS
Malig neopl uterus NOS
Malig neo endocervix
Malig neo exocervix
Malig neo cervix NEC
Mal neo cervix uteri NOS
Malignant neopl placenta
Malig neo corpus uteri
Mal neo uterine isthmus
Mal neo body uterus NEC
Malign neopl ovary
Mal neo fallopian tube
Mal neo broad ligament
Malig neo parametrium
Mal neo round ligament
Mal neo adnexa NEC
Mal neo adnexa NOS
Malign neopl vagina
Mal neo labia majora
Mal neo labia minora
Malign neopl clitoris
Malign neopl vulva NOS
Mal neo female genit NEC
Mal neo female genit NOS
Second malig neo ovary
Submucous leiomyoma
Intramural leiomyoma
Subserous leiomyoma
Uterine leiomyoma NOS
Benign neo cervix uteri
Benign neo corpus uteri
Benign neo uterus NEC
Benign neo uterus NOS
1.20 Definitions of Medicare Code Edits
220
2210
2211
2212
2218
2219
2331
2332
23330
23331
23332
23339
2360
2361
2362
2363
2560
2561
2562
25631
25639
2564
2568
2569
30273
30276
30651
30652
34640
34641
34642
34643
4566
6140
6141
6142
6143
6144
6145
6146
6147
6148
6149
6150
6151
6159
6160
61610
61611
6162
6163
6164
61650
61651
61681
61689
6169
6170
6171
6172
6173
6174
6175
6176
6178
Benign neoplasm ovary
Ben neo fallopian tube
Benign neoplasm vagina
Benign neoplasm vulva
Ben neo fem genital NEC
Ben neo fem genital NOS
Ca in situ cervix uteri
Ca in situ uterus NEC
Ca in situ fem gen NOS
Carcinoma in situ vagina
Carcinoma in situ vulva
Ca in situ fem gen NEC
Uncert behav neo uterus
Unc behav neo placenta
Unc behav neo ovary
Unc behav neo female NEC
Hyperestrogenism
Ovarian hyperfunc NEC
Postablativ ovarian fail
Premature menopause
Ovarian failure NEC
Polycystic ovaries
Ovarian dysfunction NEC
Ovarian dysfunction NOS
Female orgasmic disorder
Dyspareunia,psychogenic
Psychogenic vaginismus
Psychogenic dysmenorrhea
Menst mgr wo ntrc wo st
Menstl mgrn w ntrc wo st
Menstl mgr wo ntrc w st
Menstl mgrn w ntrc w st
Vulval varices
Ac salpingo-oophoritis
Chr salpingo-oophoritis
Salpingo-oophoritis NOS
Acute parametritis
Chronic parametritis
Ac pelv peritonitis-fem
Fem pelvic periton adhes
Chr pelv periton NEC-fem
Fem pelv inflam dis NEC
Fem pelv inflam dis NOS
Ac uterine inflammation
Chr uterine inflammation
Uterine inflam dis NOS
Cervicitis
Vaginitis NOS
Vaginitis in oth disease
Bartholin's gland cyst
Bartholin's glnd abscess
Abscess of vulva NEC
Ulceration of vulva NOS
Vulvar ulcer in oth dis
Mucositis cerv,vag,vulva
Inflm cerv,vag,vulva NEC
Female gen inflam NOS
Uterine endometriosis
Ovarian endometriosis
Tubal endometriosis
Pelv perit endometriosis
Vaginal endometriosis
Intestinal endometriosis
Endometriosis in scar
Endometriosis NEC
October 2009
Diagnoses allowed for females only
6179
61800
61801
61802
61803
61804
61805
61809
6181
6182
6183
6184
6185
6186
6187
61881
61882
61883
61884
61889
6189
6190
6191
6192
6198
6199
6200
6201
6202
6203
6204
6205
6206
6207
6208
6209
6210
6211
6212
62130
62131
62132
62133
62134
62135
6214
6215
6216
6217
6218
6219
6220
62210
62211
62212
6222
6223
6224
6225
6226
6227
6228
6229
6230
6231
6232
6233
6234
Endometriosis NOS
Vaginal wall prolpse NOS
Cystocele, midline
Cystocele, lateral
Urethrocele
Rectocele
Perineocele
Cystourethrocele
Uterine prolapse
Uterovag prolaps-incompl
Uterovag prolaps-complet
Utervaginal prolapse NOS
Postop vaginal prolapse
Vaginal enterocele
Old lacer pelvic muscle
Incomptnce pubocerv tiss
Incomptnce rectovag tiss
Pelvic muscle wasting
Cervical stump prolapse
Genital prolapse NEC
Genital prolapse NOS
Urin-genital fistul, fem
Digest-genit fistul, fem
Genital-skin fistul, fem
Fem genital fistula NEC
Fem genital fistula NOS
Follicular cyst of ovary
Corpus luteum cyst
Ovarian cyst NEC/NOS
Acq atrophy ovary & tube
Prolapse of ovary & tube
Torsion of ovary or tube
Broad ligament lacer syn
Broad ligament hematoma
Noninfl dis ova/adnx NEC
Noninfl dis ova/adnx NOS
Polyp of corpus uteri
Chr uterine subinvolutn
Hypertrophy of uterus
Endometrial hyperpla NOS
Simp endo hyper w/o atyp
Comp endo hyper w/o atyp
Endomet hyperpla w atyp
Ben endomet hyperplasia
Endomet intraepithl neop
Hematometra
Intrauterine synechiae
Malposition of uterus
Chr inversion of uterus
Disorders of uterus NEC
Disorder of uterus NOS
Erosion/ectropion cervix
Dysplasia of cervix NOS
Mild dysplasia of cervix
Mod dysplasia of cervix
Leukoplakia of cervix
Old laceration of cervix
Stricture of cervix
Incompetence of cervix
Hypertrophic elong cervx
Mucous polyp of cervix
Noninflam dis cervix NEC
Noninflam dis cervix NOS
Dysplasia of vagina
Leukoplakia of vagina
Stricture of vagina
Tight hymenal ring
Old vaginal laceration
October 2009
6235
6236
6237
6238
6239
62401
62402
62409
6241
6242
6243
6244
6245
6246
6248
6249
6250
6251
6252
6253
6254
6255
6256
62570
62571
62579
6258
6259
6260
6261
6262
6263
6264
6265
6266
6267
6268
6269
6270
6271
6272
6273
6274
6278
6279
6280
6281
6282
6283
6284
6288
6289
6290
6291
62920
62921
62922
62923
62929
62981
62989
6299
630
631
632
63300
63301
63310
Noninfect vag leukorrhea
Vaginal hematoma
Polyp of vagina
Noninflam dis vagina NEC
Noninflam dis vagina NOS
Vulvar intraeph neopl I
Vulvr intraepth neopl II
Dystrophy of vulva NEC
Atrophy of vulva
Hypertrophy of clitoris
Hypertrophy of labia
Old laceration of vulva
Hematoma of vulva
Polyp of labia and vulva
Noninflam dis vulva NEC
Noninflam dis vulva NOS
Dyspareunia
Vaginismus
Mittelschmerz
Dysmenorrhea
Premenstrual tension
Pelvic congestion synd
Fem stress incontinence
Vulvodynia NOS
Vulvar vestibulitis
Other vulvodynia
Fem genital symptoms NEC
Fem genital symptoms NOS
Absence of menstruation
Scanty menstruation
Excessive menstruation
Pubertal menorrhagia
Irregular menstruation
Ovulation bleeding
Metrorrhagia
Postcoital bleeding
Menstrual disorder NEC
Menstrual disorder NOS
Premenopause menorrhagia
Postmenopausal bleeding
Sympt fem climact state
Atrophic vaginitis
Sympt state w artif meno
Menopausal disorder NEC
Menopausal disorder NOS
Infertility-anovulation
Infertil-pituitary orig
Infertility-tubal origin
Infertility-uterine orig
Infertil-cervical orig
Female infertility NEC
Female infertility NOS
Hematocele, female NEC
Hydrocele canal nuck-fem
Genital mutilation NOS
Genital mutilatn type I
Genital mutilatn type II
Genital muilatn type III
Fem genital mutilate NEC
Hab abortr w/o curr preg
Female genital disor NEC
Female genital dis NOS
Hydatidiform mole
Oth abn prod conception
Missed abortion
Abd preg w/o intrau preg
Abd preg w intraut preg
Tubal preg w/o intra prg
Edit code lists 1.21
Diagnoses allowed for females only
63311
63320
63321
63380
63381
63390
63391
63400
63401
63402
63410
63411
63412
63420
63421
63422
63430
63431
63432
63440
63441
63442
63450
63451
63452
63460
63461
63462
63470
63471
63472
63480
63481
63482
63490
63491
63492
63500
63501
63502
63510
63511
63512
63520
63521
63522
63530
63531
63532
63540
63541
63542
63550
63551
63552
63560
63561
63562
63570
63571
63572
63580
63581
63582
63590
63591
63592
63600
Tubal preg w intra preg
Ovarn preg w/o intra prg
Ovarian preg w intra prg
Ect preg NEC w/o int prg
Ectpc prg NEC w int preg
Ect preg NOS w/o int prg
Ectp preg NOS w int preg
Spon abor w pel inf-unsp
Spon abor w pelv inf-inc
Spon abor w pel inf-comp
Spon abort w hemorr-unsp
Spon abort w hemorr-inc
Spon abort w hemorr-comp
Spon ab w pel damag-unsp
Spon ab w pelv damag-inc
Spon ab w pel damag-comp
Spon ab w ren fail-unsp
Spon ab w ren fail-inc
Spon ab w ren fail-comp
Spon ab w metab dis-unsp
Spon ab w metab dis-inc
Spon ab w metab dis-comp
Spon abort w shock-unsp
Spon abort w shock-inc
Spon abort w shock-comp
Spon abort w embol-unsp
Spon abort w embol-inc
Spon abort w embol-comp
Spon ab w compl NEC-unsp
Spon ab w compl NEC-inc
Spon ab w compl NEC-comp
Spon ab w compl NOS-unsp
Spon ab w compl NOS-inc
Spon ab w compl NOS-comp
Spon abort uncompl-unsp
Spon abort uncompl-inc
Spon abort uncompl-comp
Leg abor w pelv inf-unsp
Leg abor w pelv inf-inc
Leg abor w pelv inf-comp
Legal abor w hemorr-unsp
Legal abort w hemorr-inc
Legal abor w hemorr-comp
Leg ab w pelv damag-unsp
Leg ab w pelv damag-inc
Leg ab w pelv damag-comp
Leg abor w ren fail-unsp
Leg abor w ren fail-inc
Leg abor w ren fail-comp
Leg ab w metab dis-unsp
Leg ab w metab dis-inc
Leg ab w metab dis-comp
Legal abort w shock-unsp
Legal abort w shock-inc
Legal abort w shock-comp
Legal abort w embol-unsp
Legal abort w embol-inc
Legal abort w embol-comp
Leg ab w compl NEC-unsp
Leg ab w compl NEC-inc
Leg ab w compl NEC-comp
Leg ab w compl NOS-unsp
Leg ab w compl NOS-inc
Leg ab w compl NOS-comp
Legal abort uncompl-unsp
Legal abort uncompl-inc
Legal abort uncompl-comp
Illeg ab w pelv inf-unsp
1.22 Definitions of Medicare Code Edits
63601
63602
63610
63611
63612
63620
63621
63622
63630
63631
63632
63640
63641
63642
63650
63651
63652
63660
63661
63662
63670
63671
63672
63680
63681
63682
63690
63691
63692
63700
63701
63702
63710
63711
63712
63720
63721
63722
63730
63731
63732
63740
63741
63742
63750
63751
63752
63760
63761
63762
63770
63771
63772
63780
63781
63782
63790
63791
63792
6380
6381
6382
6383
6384
6385
6386
6387
6388
Illeg ab w pelv inf-inc
Illeg ab w pelv inf-comp
Illeg ab w hemorr-unspec
Illeg ab w hemorr-inc
Illeg ab w hemorr-comp
Illeg ab w pel damg-unsp
Illeg ab w pel damag-inc
Illeg ab w pel damg-comp
Illeg ab w ren fail-unsp
Illeg ab w ren fail-inc
Illeg ab w ren fail-comp
Illeg ab w met dis-unsp
Illeg ab w metab dis-inc
Illeg ab w met dis-comp
Illeg abort w shock-unsp
Illeg abort w shock-inc
Illeg abort w shock-comp
Illeg ab w embolism-unsp
Illeg ab w embolism-inc
Illeg ab w embolism-comp
Illg ab w compl NEC-unsp
Illeg ab w compl NEC-inc
Illg ab w compl NEC-comp
Illg ab w compl NOS-unsp
Illeg ab w compl NOS-inc
Illg ab w compl NOS-comp
Illeg abort uncompl-unsp
Illeg abort uncompl-inc
Illeg abort uncompl-comp
Abort NOS w pel inf-unsp
Abort NOS w pel inf-inc
Abort NOS w pel inf-comp
Abort NOS w hemorr-unsp
Abort NOS w hemorr-inc
Abort NOS w hemorr-comp
Ab NOS w pelv damag-unsp
Ab NOS w pelv damag-inc
Ab NOS w pelv damag-comp
Ab NOS w renal fail-unsp
Ab NOS w renal fail-inc
Ab NOS w renal fail-comp
Ab NOS w metab dis-unsp
Ab NOS w metab dis-inc
Ab NOS w metab dis-comp
Abort NOS w shock-unsp
Abort NOS w shock-inc
Abort NOS w shock-comp
Ab NOS w embolism-unsp
Ab NOS w embolism-inc
Ab NOS w embolism-comp
Ab NOS w compl NEC-unsp
Ab NOS w compl NEC-inc
Ab NOS w compl NEC-comp
Ab NOS w compl NOS-unsp
Ab NOS w compl NOS-inc
Ab NOS w compl NOS-comp
Ab NOS uncomplicat-unsp
Ab NOS uncomplicat-inc
Ab NOS uncomplicat-comp
Attem abort w pelvic inf
Attem abort w hemorrhage
Attem abort w pelv damag
Attem abort w renal fail
Attem abor w metabol dis
Attem abortion w shock
Attemp abort w embolism
Attemp abort w compl NEC
Attemp abort w compl NOS
October 2009
Diagnoses allowed for females only
6389
6390
6391
6392
6393
6394
6395
6396
6398
6399
64000
64001
64003
64080
64081
64083
64090
64091
64093
64100
64101
64103
64110
64111
64113
64120
64121
64123
64130
64131
64133
64180
64181
64183
64190
64191
64193
64200
64201
64202
64203
64204
64210
64211
64212
64213
64214
64220
64221
64222
64223
64224
64230
64231
64232
64233
64234
64240
64241
64242
64243
64244
64250
64251
64252
64253
64254
64260
Attempted abort uncompl
Postabortion gu infect
Postabortion hemorrhage
Postabort pelvic damage
Postabort kidney failure
Postabort metabolic dis
Postabortion shock
Postabortion embolism
Postabortion compl NEC
Postabortion compl NOS
Threatened abort-unspec
Threatened abort-deliver
Threaten abort-antepart
Hem early preg NEC-unsp
Hem early preg NEC-deliv
Hem early pg NEC-antepar
Hemorr early preg-unspec
Hem early preg-delivered
Hem early preg-antepart
Placenta previa-unspec
Placenta previa-deliver
Placenta previa-antepart
Placenta prev hem-unspec
Placenta prev hem-deliv
Placen prev hem-antepart
Prem separ placen-unspec
Prem separ placen-deliv
Prem separ plac-antepart
Coag def hemorr-unspec
Coag def hemorr-deliver
Coag def hemorr-antepart
Antepart hem NEC-unspec
Antepartum hem NEC-deliv
Antepart hem NEC-antepar
Antepart hem NOS-unspec
Antepartum hem NOS-deliv
Antepart hem NOS-antepar
Essen hyperten preg-unsp
Essen hyperten-delivered
Essen hyperten-del w p/p
Essen hyperten-antepart
Essen hyperten-postpart
Renal hyperten preg-unsp
Renal hyperten pg-deliv
Renal hyperten-del p/p
Renal hyperten-antepart
Renal hyperten-postpart
Old hyperten preg-unspec
Old hyperten NEC-deliver
Old hyperten-deliv w p/p
Old hyperten NEC-antepar
Old hyperten NEC-postpar
Trans hyperten preg-unsp
Trans hyperten-delivered
Trans hyperten-del w p/p
Trans hyperten-antepart
Trans hyperten-postpart
Mild/NOS preeclamp-unsp
Mild/NOS preeclamp-deliv
Mild preeclamp-del w p/p
Mild/NOS preeclamp-antep
Mild/NOS preeclamp-p/p
Severe preeclamp-unspec
Severe preeclamp-deliver
Sev preeclamp-del w p/p
Sev preeclamp-antepartum
Sev preeclamp-postpartum
Eclampsia-unspecified
October 2009
64261
64262
64263
64264
64270
64271
64272
64273
64274
64290
64291
64292
64293
64294
64300
64301
64303
64310
64311
64313
64320
64321
64323
64380
64381
64383
64390
64391
64393
64400
64403
64410
64413
64420
64421
64510
64511
64513
64520
64521
64523
64600
64601
64603
64610
64611
64612
64613
64614
64620
64621
64622
64623
64624
64630
64631
64633
64640
64641
64642
64643
64644
64650
64651
64652
64653
64654
64660
Eclampsia-delivered
Eclampsia-deliv w p/p
Eclampsia-antepartum
Eclampsia-postpartum
Tox w old hyperten-unsp
Tox w old hyperten-deliv
Tox w old hyp-del w p/p
Tox w old hyper-antepart
Tox w old hyper-postpart
Hyperten preg NOS-unspec
Hypertens NOS-delivered
Hypertens NOS-del w p/p
Hypertens NOS-antepartum
Hypertens NOS-postpartum
Mild hyperem grav-unspec
Mild hyperem grav-deliv
Mild hyperemesis-antepar
Hyperem w metab dis-unsp
Hyperem w metab dis-del
Hyperem w metab-antepart
Late vomit of preg-unsp
Late vomit of preg-deliv
Late vomit preg-antepart
Vomit compl preg-unspec
Vomit compl preg-deliver
Vomit compl preg-antepar
Vomit of preg NOS-unspec
Vomit of preg NOS-deliv
Vomit of pg NOS-antepart
Threat prem labor-unspec
Thrt prem labor-antepart
Threat labor NEC-unspec
Threat labor NEC-antepar
Early onset deliv-unspec
Early onset delivery-del
Post term preg-unsp
Post term preg-del
Post term preg-antepar
Prolonged preg-unsp
Prolonged preg-del
Prolonged preg-antepar
Papyraceous fetus-unspec
Papyraceous fetus-deliv
Papyraceous fet-antepar
Edema in preg-unspec
Edema in preg-delivered
Edema in preg-del w p/p
Edema in preg-antepartum
Edema in preg-postpartum
Renal dis preg NOS-unsp
Renal dis NOS-delivered
Renal dis NOS-del w p/p
Renal dis NOS-antepartum
Renal dis NOS-postpartum
Habitual aborter-unspec
Habitual aborter-deliver
Habitual abort-antepart
Neuritis of preg-unspec
Neuritis-delivered
Neuritis-delivered w p/p
Neuritis of preg-antepar
Neuritis of preg-postpar
Bacteriuria preg-unspec
Asym bacteriuria-deliver
Asy bacteruria-del w p/p
Asy bacteriuria-antepart
Asy bacteriuria-postpart
Gu infect in preg-unspec
Edit code lists 1.23
Diagnoses allowed for females only
64661
64662
64663
64664
64670
64671
64673
64680
64681
64682
64683
64684
64690
64691
64693
64700
64701
64702
64703
64704
64710
64711
64712
64713
64714
64720
64721
64722
64723
64724
64730
64731
64732
64733
64734
64740
64741
64742
64743
64744
64750
64751
64752
64753
64754
64760
64761
64762
64763
64764
64780
64781
64782
64783
64784
64790
64791
64792
64793
64794
64800
64801
64802
64803
64804
64810
64811
64812
Gu infection-delivered
Gu infection-deliv w p/p
Gu infection-antepartum
Gu infection-postpartum
Liver dis in preg-unspec
Liver disorder-delivered
Liver disorder-antepart
Preg compl NEC-unspec
Preg compl NEC-delivered
Preg compl NEC-del w p/p
Preg compl NEC-antepart
Preg compl NEC-postpart
Preg compl NOS-unspec
Preg compl NOS-delivered
Preg compl NOS-antepart
Syphilis in preg-unspec
Syphilis-delivered
Syphilis-delivered w p/p
Syphilis-antepartum
Syphilis-postpartum
Gonorrhea in preg-unspec
Gonorrhea-delivered
Gonorrhea-deliver w p/p
Gonorrhea-antepartum
Gonorrhea-postpartum
Other VD in preg-unspec
Other vd-delivered
Other vd-delivered w p/p
Other vd-antepartum
Other vd-postpartum
TB in preg-unspecified
Tuberculosis-delivered
Tuberculosis-deliv w p/p
Tuberculosis-antepartum
Tuberculosis-postpartum
Malaria in preg-unspec
Malaria-delivered
Malaria-delivered w p/p
Malaria-antepartum
Malaria-postpartum
Rubella in preg-unspec
Rubella-delivered
Rubella-delivered w p/p
Rubella-antepartum
Rubella-postpartum
Oth virus in preg-unspec
Oth viral dis-delivered
Oth viral dis-del w p/p
Oth viral dis-antepartum
Oth viral dis-postpartum
Inf dis in preg NEC-unsp
Infect dis NEC-delivered
Infect dis NEC-del w p/p
Infect dis NEC-antepart
Infect dis NEC-postpart
Infect in preg NOS-unsp
Infect NOS-delivered
Infect NOS-deliver w p/p
Infect NOS-antepartum
Infect NOS-postpartum
Diabetes in preg-unspec
Diabetes-delivered
Diabetes-delivered w p/p
Diabetes-antepartum
Diabetes-postpartum
Thyroid dysfun preg-unsp
Thyroid dysfunc-deliver
Thyroid dysfun-del w p/p
1.24 Definitions of Medicare Code Edits
64813
64814
64820
64821
64822
64823
64824
64830
64831
64832
64833
64834
64840
64841
64842
64843
64844
64850
64851
64852
64853
64854
64860
64861
64862
64863
64864
64870
64871
64872
64873
64874
64880
64881
64882
64883
64884
64890
64891
64892
64893
64894
64900
64901
64902
64903
64904
64910
64911
64912
64913
64914
64920
64921
64922
64923
64924
64930
64931
64932
64933
64934
64940
64941
64942
64943
64944
64950
Thyroid dysfunc-antepart
Thyroid dysfunc-postpart
Anemia in preg-unspec
Anemia-delivered
Anemia-delivered w p/p
Anemia-antepartum
Anemia-postpartum
Drug depend preg-unspec
Drug dependence-deliver
Drug dependen-del w p/p
Drug dependence-antepart
Drug dependence-postpart
Mental dis preg-unspec
Mental disorder-deliver
Mental dis-deliv w p/p
Mental disorder-antepart
Mental disorder-postpart
Congen CV dis preg-unsp
Congen CV dis-delivered
Congen CV dis-del w p/p
Congen CV dis-antepartum
Congen CV dis-postpartum
CV dis NEC preg-unspec
CV dis NEC preg-deliver
CV dis NEC-deliver w p/p
CV dis NEC-antepartum
CV dis NEC-postpartum
Bone disord in preg-unsp
Bone disorder-delivered
Bone disorder-del w p/p
Bone disorder-antepartum
Bone disorder-postpartum
Abn glucose in preg-unsp
Abn glucose toler-deliv
Abn glucose-deliv w p/p
Abn glucose-antepartum
Abn glucose-postpartum
Oth curr cond preg-unsp
Oth curr cond-delivered
Oth curr cond-del w p/p
Oth curr cond-antepartum
Oth curr cond-postpartum
Tobacco use disord-unsp
Tobacco use disor-delliv
Tobacco use dis-del-p/p
Tobacco use dis-antepart
Tobacco use dis-postpart
Obesity-unspecified
Obesity-delivered
Obesity-delivered w p/p
Obesity-antepartum
Obesity-postpartum
Bariatric surg stat-unsp
Bariatric surg stat-del
Bariatric surg-del w p/p
Bariatrc surg stat-antep
Bariatrc surg stat w p/p
Coagulation def-unspec
Coagulation def-deliv
Coagulatn def-del w p/p
Coagulation def-antepart
Coagulation def-postpart
Epilepsy-unspecified
Epilepsy-delivered
Epilepsy-delivered w p/p
Epilepsy-antepartum
Epilepsy-postpartum
Spotting-unspecified
October 2009
Diagnoses allowed for females only
64951
64953
64960
64961
64962
64963
64964
64970
64971
64973
650
65100
65101
65103
65110
65111
65113
65120
65121
65123
65130
65131
65133
65140
65141
65143
65150
65151
65153
65160
65161
65163
65170
65171
65173
65180
65181
65183
65190
65191
65193
65200
65201
65203
65210
65211
65213
65220
65221
65223
65230
65231
65233
65240
65241
65243
65250
65251
65253
65260
65261
65263
65270
65271
65273
65280
65281
65283
Spotting-delivered
Spotting-antepartum
Uterine size descrp-unsp
Uterine size descrep-del
Uterine size-del w p/p
Uterine size des-antepar
Uterine size descrep-p/p
Cervical shortening-unsp
Cervical shortening-del
Cervical shortening-ante
Normal delivery
Twin pregnancy-unspec
Twin pregnancy-delivered
Twin pregnancy-antepart
Triplet pregnancy-unspec
Triplet pregnancy-deliv
Triplet preg-antepartum
Quadruplet preg-unspec
Quadruplet preg-deliver
Quadruplet preg-antepart
Twins w fetal loss-unsp
Twins w fetal loss-del
Twins w fetal loss-ante
Triplets w fet loss-unsp
Triplets w fet loss-del
Triplets w fet loss-ante
Quads w fetal loss-unsp
Quads w fetal loss-del
Quads w fetal loss-ante
Mult ges w fet loss-unsp
Mult ges w fet loss-del
Mult ges w fet loss-ante
Mul gest-fet reduct unsp
Mult gest-fet reduct del
Mul gest-fet reduct ante
Multi gestat NEC-unspec
Multi gestat NEC-deliver
Multi gest NEC-antepart
Multi gestat NOS-unspec
Mult gestation NOS-deliv
Multi gest NOS-antepart
Unstable lie-unspecified
Unstable lie-delivered
Unstable lie-antepartum
Cephalic vers NOS-unspec
Cephalic vers NOS-deliv
Cephal vers NOS-antepart
Breech presentat-unspec
Breech presentat-deliver
Breech present-antepart
Transv/obliq lie-unspec
Transver/obliq lie-deliv
Transv/obliq lie-antepar
Face/brow present-unspec
Face/brow present-deliv
Face/brow pres-antepart
High head at term-unspec
High head at term-deliv
High head term-antepart
Mult gest malpresen-unsp
Mult gest malpres-deliv
Mult ges malpres-antepar
Prolapsed arm-unspec
Prolapsed arm-delivered
Prolapsed arm-antepart
Malposition NEC-unspec
Malposition NEC-deliver
Malposition NEC-antepart
October 2009
65290
65291
65293
65300
65301
65303
65310
65311
65313
65320
65321
65323
65330
65331
65333
65340
65341
65343
65350
65351
65353
65360
65361
65363
65370
65371
65373
65380
65381
65383
65390
65391
65393
65400
65401
65402
65403
65404
65410
65411
65412
65413
65414
65420
65421
65423
65430
65431
65432
65433
65434
65440
65441
65442
65443
65444
65450
65451
65452
65453
65454
65460
65461
65462
65463
65464
65470
65471
Malposition NOS-unspec
Malposition NOS-deliver
Malposition NOS-antepart
Pelvic deform NOS-unspec
Pelvic deform NOS-deliv
Pelv deform NOS-antepart
Contract pelv NOS-unspec
Contract pelv NOS-deliv
Contrac pelv NOS-antepar
Inlet contraction-unspec
Inlet contraction-deliv
Inlet contract-antepart
Outlet contraction-unsp
Outlet contraction-deliv
Outlet contract-antepart
Fetopelv disprop-unspec
Fetopelv dispropor-deliv
Fetopel disprop-antepart
Fetal disprop NOS-unspec
Fetal disprop NOS-deliv
Fetal dispro NOS-antepar
Hydrocephal fetus-unspec
Hydroceph fetus-deliver
Hydroceph fetus-antepart
Oth abn fet disprop-unsp
Oth abn fet dispro-deliv
Oth abn fet dispro-antep
Disproportion NEC-unspec
Disproportion NEC-deliv
Dispropor NEC-antepartum
Disproportion NOS-unspec
Disproportion NOS-deliv
Dispropor NOS-antepartum
Cong abn uter preg-unsp
Congen abn uterus-deliv
Cong abn uter-del w p/p
Congen abn uter-antepart
Congen abn uter-postpart
Uter tumor in preg-unsp
Uterine tumor-delivered
Uterine tumor-del w p/p
Uterine tumor-antepartum
Uterine tumor-postpartum
Prev c-delivery unspec
Prev c-delivery-delivrd
Prev c-delivery-antepart
Retrovert uterus-unspec
Retrovert uterus-deliver
Retrovert uter-del w p/p
Retrovert uter-antepart
Retrovert uter-postpart
Abn grav uterus NEC-unsp
Abn uterus NEC-delivered
Abn uterus NEC-del w p/p
Abn uterus NEC-antepart
Abn uterus NEC-postpart
Cerv incompet preg-unsp
Cervical incompet-deliv
Cerv incompet-del w p/p
Cerv incompet-antepartum
Cerv incompet-postpartum
Abn cervix NEC preg-unsp
Abn cervix NEC-delivered
Abn cervix NEC-del w p/p
Abn cervix NEC-antepart
Abn cervix NEC-postpart
Abn vagina in preg-unsp
Abnorm vagina-delivered
Edit code lists 1.25
Diagnoses allowed for females only
65472
65473
65474
65480
65481
65482
65483
65484
65490
65491
65492
65493
65494
65500
65501
65503
65510
65511
65513
65520
65521
65523
65530
65531
65533
65540
65541
65543
65550
65551
65553
65560
65561
65563
65570
65571
65573
65580
65581
65583
65590
65591
65593
65600
65601
65603
65610
65611
65613
65620
65621
65623
65630
65631
65633
65640
65641
65643
65650
65651
65653
65660
65661
65663
65670
65671
65673
65680
Abnorm vagina-del w p/p
Abnorm vagina-antepartum
Abnorm vagina-postpartum
Abn vulva in preg-unspec
Abnormal vulva-delivered
Abnormal vulva-del w p/p
Abnormal vulva-antepart
Abnormal vulva-postpart
Abn pel NEC in preg-unsp
Abn pelv org NEC-deliver
Abn pelv NEC-deliv w p/p
Abn pelv org NEC-antepar
Abn pelv org NEC-postpar
Fetal cns malform-unspec
Fetal cns malform-deliv
Fetal cns malfor-antepar
Fetal chromos abn-unspec
Fetal chromoso abn-deliv
Fet chromo abn-antepart
Famil heredit dis-unspec
Famil heredit dis-deliv
Famil hered dis-antepart
Fet damg d/t virus-unsp
Fet damg d/t virus-deliv
Fet damg d/t virus-antep
Fet damg d/t dis-unspec
Fet damg d/t dis-deliver
Fet damg d/t dis-antepar
Fetal damg d/t drug-unsp
Fet damag d/t drug-deliv
Fet damg d/t drug-antepa
Radiat fetal damag-unsp
Radiat fetal damag-deliv
Radiat fet damag-antepar
Decrease fetl movmt unsp
Decrease fetal movmt del
Dec fetal movmt antepart
Fetal abnorm NEC-unspec
Fetal abnorm NEC-deliver
Fetal abnorm NEC-antepar
Fetal abnorm NOS-unspec
Fetal abnorm NOS-deliver
Fetal abnorm NOS-antepar
Fetal-maternal hem-unsp
Fetal-maternal hem-deliv
Fetal-matern hem-antepar
Rh isoimmunization-unsp
Rh isoimmunizat-deliver
Rh isoimmunizat-antepart
Abo isoimmunization-unsp
Abo isoimmunizat-deliver
Abo isoimmunizat-antepar
Fetal distress-unspec
Fetal distress-delivered
Fetal distress-antepart
Intrauterine death-unsp
Intrauter death-deliver
Intrauter death-antepart
Poor fetal growth-unspec
Poor fetal growth-deliv
Poor fetal grth-antepart
Excess fetal grth-unspec
Excess fetal grth-deliv
Excess fet grth-antepart
Oth placent cond-unspec
Oth placent cond-deliver
Oth placent cond-antepar
Fet/plac prob NEC-unspec
1.26 Definitions of Medicare Code Edits
65681
65683
65690
65691
65693
65700
65701
65703
65800
65801
65803
65810
65811
65813
65820
65821
65823
65830
65831
65833
65840
65841
65843
65880
65881
65883
65890
65891
65893
65900
65901
65903
65910
65911
65913
65920
65921
65923
65930
65931
65933
65940
65941
65943
65950
65951
65953
65960
65961
65963
65970
65971
65973
65980
65981
65983
65990
65991
65993
66000
66001
66003
66010
66011
66013
66020
66021
66023
Fet/plac prob NEC-deliv
Fet/plac prob NEC-antepa
Fet/plac prob NOS-unspec
Fet/plac prob NOS-deliv
Fet/plac prob NOS-antepa
Polyhydramnios-unspec
Polyhydramnios-delivered
Polyhydramnios-antepart
Oligohydramnios-unspec
Oligohydramnios-deliver
Oligohydramnios-antepar
Prem rupt membran-unspec
Prem rupt membran-deliv
Prem rupt memb-antepart
Prolong rupt memb-unspec
Prolong rupt memb-deliv
Prolong rup memb-antepar
Artific rupt membr-unsp
Artific rupt membr-deliv
Artif rupt memb-antepart
Amniotic infection-unsp
Amniotic infection-deliv
Amniotic infect-antepart
Amniotic prob NEC-unspec
Amniotic prob NEC-deliv
Amnion prob NEC-antepart
Amniotic prob NOS-unspec
Amniotic prob NOS-deliv
Amnion prob NOS-antepart
Fail mechan induct-unsp
Fail mech induct-deliver
Fail mech induct-antepar
Fail induction NOS-unsp
Fail induction NOS-deliv
Fail induct NOS-antepart
Pyrexia in labor-unspec
Pyrexia in labor-deliver
Pyrexia in labor-antepar
Septicemia in labor-unsp
Septicem in labor-deliv
Septicem in labor-antepa
Grand multiparity-unspec
Grand multiparity-deliv
Grand multiparity-antepa
Elderly primigravid-unsp
Elderly primigravida-del
Elder primigravid-antepa
Elderly multigravida-uns
Elderly multigravida-del
Elderly multigravd-antep
Abn ftl hrt rate/rhy-uns
Abn ftl hrt rate/rhy-del
Abn ftl hrt rate/rhy-ant
Complic labor NEC-unsp
Complic labor NEC-deliv
Compl labor NEC-antepart
Complic labor NOS-unsp
Complic labor NOS-deliv
Compl labor NOS-antepart
Obstruct/fet malpos-unsp
Obstruc/fet malpos-deliv
Obstruc/fet malpos-antep
Bony pelv obstruc-unspec
Bony pelv obstruct-deliv
Bony pelv obstruc-antepa
Abn pelv tiss obstr-unsp
Abn pelv tis obstr-deliv
Abn pelv tis obstr-antep
October 2009
Diagnoses allowed for females only
66030
66031
66033
66040
66041
66043
66050
66051
66053
66060
66061
66063
66070
66071
66073
66080
66081
66083
66090
66091
66093
66100
66101
66103
66110
66111
66113
66120
66121
66123
66130
66131
66133
66140
66141
66143
66190
66191
66193
66200
66201
66203
66210
66211
66213
66220
66221
66223
66230
66231
66233
66300
66301
66303
66310
66311
66313
66320
66321
66323
66330
66331
66333
66340
66341
66343
66350
66351
Persist occipitpost-unsp
Persist occiptpost-deliv
Persist occiptpost-antep
Shoulder dystocia-unspec
Shoulder dystocia-deliv
Shoulder dystocia-antepa
Locked twins-unspecified
Locked twins-delivered
Locked twins-antepartum
Fail trial lab NOS-unsp
Fail trial lab NOS-deliv
Fail trial lab NOS-antep
Failed forcep NOS-unspec
Failed forceps NOS-deliv
Fail forceps NOS-antepar
Obstruc labor NEC-unspec
Obstruct labor NEC-deliv
Obstruc labor NEC-antepa
Obstruc labor NOS-unspec
Obstruct labor NOS-deliv
Obstruc labor NOS-antepa
Prim uterine inert-unsp
Prim uterine inert-deliv
Prim uter inert-antepart
Sec uterine inert-unspec
Sec uterine inert-deliv
Sec uterine inert-antepa
Uterine inertia NEC-unsp
Uterine inert NEC-deliv
Uterine inert NEC-antepa
Precipitate labor-unspec
Precipitate labor-deliv
Precipitate labor-antepa
Uter dystocia NOS-unspec
Uter dystocia NOS-deliv
Uter dystocia NOS-antepa
Abnormal labor NOS-unsp
Abnormal labor NOS-deliv
Abnorm labor NOS-antepar
Prolonged 1st stage-unsp
Prolong 1st stage-deliv
Prolong 1st stage-antepa
Prolonged labor NOS-unsp
Prolong labor NOS-deliv
Prolong labor NOS-antepa
Prolonged 2nd stage-unsp
Prolong 2nd stage-deliv
Prolong 2nd stage-antepa
Delay del 2nd twin-unsp
Delay del 2nd twin-deliv
Delay del 2 twin-antepar
Cord prolapse-unspec
Cord prolapse-delivered
Cord prolapse-antepartum
Cord around neck-unspec
Cord around neck-deliver
Cord around neck-antepar
Cord compress NEC-unspec
Cord compress NEC-deliv
Cord compres NEC-antepar
Cord entangle NEC-unspec
Cord entangle NEC-deliv
Cord entangl NEC-antepar
Short cord-unspecified
Short cord-delivered
Short cord-antepartum
Vasa previa-unspecified
Vasa previa-delivered
October 2009
66353
66360
66361
66363
66380
66381
66383
66390
66391
66393
66400
66401
66404
66410
66411
66414
66420
66421
66424
66430
66431
66434
66440
66441
66444
66450
66451
66454
66460
66461
66464
66480
66481
66484
66490
66491
66494
66500
66501
66503
66510
66511
66520
66522
66524
66530
66531
66534
66540
66541
66544
66550
66551
66554
66560
66561
66564
66570
66571
66572
66574
66580
66581
66582
66583
66584
66590
66591
Vasa previa-antepartum
Vasc lesion cord-unspec
Vasc lesion cord-deliver
Vasc lesion cord-antepar
Cord complicat NEC-unsp
Cord complicat NEC-deliv
Cord compl NEC-antepart
Cord complicat NOS-unsp
Cord complicat NOS-deliv
Cord compl NOS-antepart
Del w 1 deg lacerat-unsp
Del w 1 deg lacerat-del
Del w 1 deg lac-postpart
Del w 2 deg lacerat-unsp
Del w 2 deg lacerat-del
Del w 2 deg lac-postpart
Del w 3 deg lacerat-unsp
Del w 3 deg lacerat-del
Del w 3 deg lac-postpart
Del w 4 deg lacerat-unsp
Del w 4 deg lacerat-del
Del w 4 deg lac-postpart
Ob perineal lac NOS-unsp
Ob perineal lac NOS-del
Perineal lac NOS-postpar
Ob perineal hematom-unsp
Ob perineal hematoma-del
Perin hematoma-postpart
Anal sphincter tear NOS
Anal sphincter tear-del
Anal sphinctr tear w p/p
Ob perin traum NEC-unsp
Ob perineal trau NEC-del
Perin traum NEC-postpart
Ob perin traum NOS-unsp
Ob perineal trau NOS-del
Perin traum NOS-postpart
Prelabor rupt uter-unsp
Prelabor rupt uterus-del
Prelab rupt uter-antepar
Rupture uterus NOS-unsp
Rupture uterus NOS-deliv
Inversion of uterus-unsp
Invers uterus-del w p/p
Invers uterus-postpart
Lacerat of cervix-unspec
Lacerat of cervix-deliv
Lacer of cervix-postpart
High vaginal lacer-unsp
High vaginal lacer-deliv
High vaginal lac-postpar
Ob inj pelv org NEC-unsp
Ob inj pelv org NEC-del
Inj pelv org NEC-postpar
Damage to pelvic jt-unsp
Damage to pelvic jt-del
Damage pelvic jt-postpar
Ob pelvic hematoma-unsp
Ob pelvic hematoma-deliv
Pelvic hematom-del w pp
Pelvic hematoma-postpart
Ob trauma NEC-unspec
Ob trauma NEC-delivered
Ob trauma NEC-del w p/p
Ob trauma NEC-antepartum
Ob trauma NEC-postpartum
Ob trauma NOS-unspec
Ob trauma NOS-delivered
Edit code lists 1.27
Diagnoses allowed for females only
66592
66593
66594
66600
66602
66604
66610
66612
66614
66620
66622
66624
66630
66632
66634
66700
66702
66704
66710
66712
66714
66800
66801
66802
66803
66804
66810
66811
66812
66813
66814
66820
66821
66822
66823
66824
66880
66881
66882
66883
66884
66890
66891
66892
66893
66894
66900
66901
66902
66903
66904
66910
66911
66912
66913
66914
66920
66921
66922
66923
66924
66930
66932
66934
66940
66941
66942
66943
Ob trauma NOS-del w p/p
Ob trauma NOS-antepartum
Ob trauma NOS-postpartum
Third-stage hem-unspec
Thrd-stage hem-del w p/p
Third-stage hem-postpart
Postpartum hem NEC-unsp
Postpa hem NEC-del w p/p
Postpart hem NEC-postpar
Delay p/part hem-unspec
Delay p/p hem-del w p/p
Delay p/part hem-postpar
Postpart coagul def-unsp
P/p coag def-del w p/p
Postpart coag def-postpa
Retain placenta NOS-unsp
Retnd plac NOS-del w p/p
Retain plac NOS-postpart
Retain prod concept-unsp
Ret prod conc-del w p/p
Ret prod concept-postpar
Pulm compl in del-unspec
Pulm compl in del-deliv
Pulm complic-del w p/p
Pulm complicat-antepart
Pulm complicat-postpart
Heart compl in del-unsp
Heart compl in del-deliv
Heart compl-del w p/p
Heart complic-antepart
Heart complic-postpart
Cns compl labor/del-unsp
Cns compl lab/del-deliv
Cns complic-del w p/p
Cns compl in del-antepar
Cns compl in del-postpar
Anesth comp del NEC-unsp
Anesth compl NEC-deliver
Anesth compl NEC-del p/p
Anesth compl antepartum
Anesth compl-postpartum
Anesth comp del NOS-unsp
Anesth compl NOS-deliver
Anesth compl NOS-del p/p
Anesth compl-antepartum
Anesth compl-postpartum
Maternal distress-unspec
Maternal distress-deliv
Matern distres-del w p/p
Matern distress-antepar
Matern distress-postpart
Obstetric shock-unspec
Obstetric shock-deliver
Obstet shock-deliv w p/p
Obstetric shock-antepar
Obstetric shock-postpart
Matern hypotens syn-unsp
Matern hypoten syn-deliv
Matern hypoten-del w p/p
Matern hypotens-antepar
Matern hypotens-postpart
Ac kidny fail w del-unsp
Ac kidney fail-del w p/p
Ac kidney fail-postpart
Oth ob surg compl-unspec
Oth ob compl-delivered
Oth ob compl-deliv w p/p
Complc ob surg anteprtm
1.28 Definitions of Medicare Code Edits
66944
66950
66951
66960
66961
66970
66971
66980
66981
66982
66983
66984
66990
66991
66992
66993
66994
67000
67002
67004
67010
67012
67014
67020
67022
67024
67030
67032
67034
67080
67082
67084
67100
67101
67102
67103
67104
67110
67111
67112
67113
67114
67120
67121
67122
67123
67124
67130
67131
67133
67140
67142
67144
67150
67151
67152
67153
67154
67180
67181
67182
67183
67184
67190
67191
67192
67193
67194
Oth ob surg compl-postpa
Forcep deliv NOS-unspec
Forcep deliv NOS-deliver
Breech extr NOS-unspec
Breech extr NOS-deliver
Cesarean deliv NOS-unsp
Cesarean delivery NOS
Compl lab/deliv NEC-unsp
Comp lab/deliv NEC-deliv
Compl del NEC-del w p/p
Compl deliv NEC-antepar
Compl deliv NEC-postpart
Compl lab/deliv NOS-unsp
Comp lab/deliv NOS-deliv
Compl del NOS-del w p/p
Compl deliv NOS-antepar
Compl deliv NOS-postpart
Maj puerp inf NOS-unsp
Maj puer inf NOS-del p/p
Major puerp inf NOS-p/p
Puerp endometritis-unsp
Puerp endomet del w p/p
Puerp endomet-postpart
Puerperal sepsis-unsp
Puerprl sepsis-del w p/p
Puerperl sepsis-postpart
Puerp septc thromb-unsp
Prp sptc thrmb-del w p/p
Prp septc thrmb-postpart
Maj prp infec NEC-unspec
Maj prp inf NEC-dl w p/p
Maj puerp infec NEC-p/p
Varic vein leg preg-unsp
Varicose vein leg-deliv
Varic vein leg-del w p/p
Varic vein leg-antepart
Varic vein leg-postpart
Varic vulva preg-unspec
Varicose vulva-delivered
Varicose vulva-del w p/p
Varicose vulva-antepart
Varicose vulva-postpart
Thrombophleb preg-unspec
Thrombophlebitis-deliver
Thrombophleb-deliv w p/p
Thrombophlebit-antepart
Thrombophlebit-postpart
Deep thromb antepar-unsp
Deep throm antepar-deliv
Deep vein thromb-antepar
Deep thromb postpar-unsp
Thromb postpar-del w p/p
Deep vein thromb-postpar
Thrombosis NEC preg-unsp
Thrombosis NEC-delivered
Thromb NEC-deliv w p/p
Thrombosis NEC-antepart
Thrombosis NEC-postpart
Ven compl preg NEC-unsp
Venous compl NEC-deliver
Ven comp NEC-deliv w p/p
Venous compl NEC-antepar
Venous compl NEC-postpar
Ven compl preg NOS-unsp
Venous compl NOS-deliver
Ven comp NOS-deliv w p/p
Venous compl NOS-antepar
Venous compl NOS-postpar
October 2009
Diagnoses allowed for females only
67200
67202
67204
67300
67301
67302
67303
67304
67310
67311
67312
67313
67314
67320
67321
67322
67323
67324
67330
67331
67332
67333
67334
67380
67381
67382
67383
67384
67400
67401
67402
67403
67404
67410
67412
67414
67420
67422
67424
67430
67432
67434
67440
67442
67444
67450
67451
67452
67453
67454
67480
67482
67484
67490
67492
67494
67500
67501
67502
67503
67504
67510
67511
67512
67513
67514
67520
67521
Puerperal pyrexia-unspec
Puerp pyrexia-del w p/p
Puerp pyrexia-postpartum
Ob air embolism-unspec
Ob air embolism-deliver
Ob air embol-deliv w p/p
Ob air embolism-antepart
Ob air embolism-postpart
Amniotic embolism-unspec
Amniotic embolism-deliv
Amniot embol-deliv w p/p
Amniotic embol-antepart
Amniotic embol-postpart
Ob pulm embol NOS-unspec
Pulm embol NOS-delivered
Pulm embol NOS-del w p/p
Pulm embol NOS-antepart
Pulm embol NOS-postpart
Ob pyemic embol-unspec
Ob pyemic embol-deliver
Ob pyem embol-del w p/p
Ob pyemic embol-antepart
Ob pyemic embol-postpart
Ob pulmon embol NEC-unsp
Pulmon embol NEC-deliver
Pulm embol NEC-del w p/p
Pulmon embol NEC-antepar
Pulmon embol NEC-postpar
Puerp cerebvasc dis-unsp
Puerp cerebvas dis-deliv
Cerebvas dis-deliv w p/p
Cerebrovasc dis-antepart
Cerebrovasc dis-postpart
Disrupt c-sect wnd-unsp
Disrupt c-sect-del w p/p
Disrupt c-sect-postpart
Disrupt perineum-unspec
Disrupt perin-del w p/p
Disrupt perineum-postpar
Ob surg compl NEC-unspec
Ob surg compl-del w p/p
Ob surg comp NEC-postpar
Placental polyp-unspec
Placent polyp-del w p/p
Placental polyp-postpart
Peripart cardiomy-unspec
Peripartum cardiomy-del
Peripart card del w p/p
Peripartum card-antepart
Peripartum card-postpart
Puerp compl NEC-unspec
Puerp comp NEC-del w p/p
Puerp compl NEC-postpart
Puerp compl NOS-unspec
Puerp comp NOS-del w p/p
Puerp compl NOS-postpart
Infect nipple preg-unsp
Infect nipple-delivered
Infect nipple-del w p/p
Infect nipple-antepartum
Infect nipple-postpartum
Breast abscess preg-unsp
Breast abscess-delivered
Breast abscess-del w p/p
Breast abscess-antepart
Breast abscess-postpart
Mastitis in preg-unspec
Mastitis-delivered
October 2009
67522
67523
67524
67580
67581
67582
67583
67584
67590
67591
67592
67593
67594
67600
67601
67602
67603
67604
67610
67611
67612
67613
67614
67620
67621
67622
67623
67624
67630
67631
67632
67633
67634
67640
67641
67642
67643
67644
67650
67651
67652
67653
67654
67660
67661
67662
67663
67664
67680
67681
67682
67683
67684
67690
67691
67692
67693
67694
677
67800
67801
67803
67810
67811
67813
67900
67901
67902
Mastitis-deliv w p/p
Mastitis-antepartum
Mastitis-postpartum
Breast inf preg NEC-unsp
Breast infect NEC-deliv
Breast inf NEC-del w p/p
Breast inf NEC-antepart
Breast inf NEC-postpart
Breast inf preg NOS-unsp
Breast infect NOS-deliv
Breast inf NOS-del w p/p
Breast inf NOS-antepart
Breast inf NOS-postpart
Retract nipple preg-unsp
Retracted nipple-deliver
Retract nipple-del w p/p
Retract nipple-antepart
Retract nipple-postpart
Cracked nipple preg-unsp
Cracked nipple-delivered
Cracked nipple-del w p/p
Cracked nipple-antepart
Cracked nipple-postpart
Breast engorge-unspec
Breast engorge-delivered
Breast engorge-del w p/p
Breast engorge-antepart
Breast engorge-postpart
Breast dis preg NEC-unsp
Breast dis NEC-delivered
Breast dis NEC-del w p/p
Breast dis NEC-antepart
Breast dis NEC-postpart
Lactation fail-unspec
Lactation fail-delivered
Lactation fail-del w p/p
Lactation fail-antepart
Lactation fail-postpart
Suppr lactation-unspec
Suppr lactation-deliver
Suppr lactat-del w p/p
Suppr lactation-antepar
Suppr lactation-postpart
Galactorrhea preg-unspec
Galactorrhea-delivered
Galactorrhea-del w p/p
Galactorrhea-antepartum
Galactorrhea-postpartum
Lactation dis NEC-unspec
Lactation dis NEC-deliv
Lactat dis NEC-del w p/p
Lactat dis NEC-antepart
Lactat dis NEC-postpart
Lactation dis NOS-unspec
Lactation dis NOS-deliv
Lactat dis NOS-del w p/p
Lactat dis NOS-antepart
Lactat dis NOS-postpart
Late effct cmplcatn preg
Fetal hematologic-unspec
Fetal hematologic-deliv
Fetal hematologic-ante
Fetal conjoin twins-unsp
Fetal conjoin twins-del
Fetal conjoin twins-ante
Mat comp in utero-unsp
Mat comp in utero-del
Mat comp in utro-del-p/p
Edit code lists 1.29
Diagnoses allowed for females only
67903
67904
67910
67911
67912
67913
67914
71630
71631
71632
71633
71634
71635
71636
71637
71638
71639
7520
75210
75211
75219
7522
7523
75240
75241
75242
75249
7923
79500
79501
79502
79503
79504
79505
79506
79507
79508
79509
79510
79511
79512
79513
79514
79515
79516
79518
79519
79582
7965
8674
8675
8784
8785
8786
8787
90255
90256
90281
90282
9391
9392
9474
99632
V074
V1040
V1041
V1042
V1043
Mat comp in utero-ante
Mat comp in utero-p/p
Fetal comp in utero-unsp
Fetal comp in utero-del
Ftl cmp in utro-del-p/p
Fetal comp in utero-ante
Fetal comp in utero-p/p
Climact arthritis-unspec
Climact arthritis-shlder
Climact arthritis-up/arm
Climact arthrit-forearm
Climact arthritis-hand
Climact arthritis-pelvis
Climact arthritis-l/leg
Climact arthritis-ankle
Climact arthritis NEC
Climact arthritis-mult
Anomalies of ovaries
Tubal/broad lig anom NOS
Embryonic cyst of adnexa
Tubal/broad lig anom NEC
Doubling of uterus
Uterine anomaly NEC
Cervix/fem gen anom NOS
Embryon cyst fem gen NEC
Imperforate hymen
Cervix/fem gen anom NEC
Abn find-amniotic fluid
Abn glandular pap smear
Pap smear (ASC-US)
Pap smear (ASC-H)
Pap smear cervix w LGSIL
Pap smear cervix w HGSIL
Cervical (HPV) DNA pos
Pap smr cytol evid malig
Sat cerv smr-no trnsfrm
Unsat cerv cytlogy smear
Abn pap cervix HPV NEC
Abn gland pap smr vagina
Pap smear vag w ASC-US
Pap smear vagina w ASC-H
Pap smear vagina w LGSIL
Pap smear vagina w HGSIL
Vag hi risk HPV-DNA pos
Pap smr vag-cytol malig
Vaginl cytol smr unsatis
Oth abn Pap smr vag/HPV
Elev ca antigen 125
Abn find antenatl screen
Uterus injury-closed
Uterus injury-open
Open wound of vulva
Open wound vulva-compl
Open wound of vagina
Open wound vagina-compl
Injury uterine artery
Injury uterine vein
Injury ovarian artery
Injury ovarian vein
Foreign body uterus
Foreign bdy vulva/vagina
Burn of vagina & uterus
Malfunction iud
Hormone replace postmeno
Hx-female genit malg NOS
Hx-cervical malignancy
Hx-uterus malignancy NEC
Hx of ovarian malignancy
1.30 Definitions of Medicare Code Edits
V1044
V131
V1321
V1322
V1329
V1521
V220
V221
V222
V230
V231
V232
V233
V2341
V2349
V235
V237
V2381
V2382
V2383
V2384
V2385
V2386
V2389
V239
V240
V241
V242
V2501
V251
V253
V2541
V2542
V2543
V255
V261
V2631
V2632
V2651
V2681
V270
V271
V272
V273
V274
V275
V276
V277
V279
V280
V281
V282
V283
V284
V285
V286
V2881
V2882
V2889
V289
V4551
V4981
V5042
V524
V5970
V5971
V5972
V5973
Hx-female genit malg NEC
Hx-trophoblastic disease
History-pre-term labor
Hx of cervical dysplasia
Hx-genital/obs dis NEC
Hx in utero proc in preg
Supervis normal 1st preg
Supervis oth normal preg
Preg state, incidental
Preg w hx of infertility
Preg w hx-trophoblas dis
Preg w hx of abortion
Grand multiparity
Preg w hx pre-term labor
Preg w poor obs hx NEC
Preg w poor reproduct hx
Insufficnt prenatal care
Suprv elderly primigrav
Suprv elderly multigrav
Suprv young primigravida
Suprv young multigravida
Pregnt-assist repro tech
Preg-hx in utro prev prg
Suprv high-risk preg NEC
Suprv high-risk preg NOS
Postpart care after del
Postpart care-lactation
Rout postpart follow-up
Prescrip-oral contracept
Insertion of iud
Menstrual extraction
Contracept pill surveill
Iud surveillance
Srvl mplnt sbdrm cntrcep
Nsrt mplnt sbdrm cntrcep
Artificial insemination
Fem genetic test dis car
Female genetic test NEC
Tubal ligation status
Assist repro fertility
Deliver-single liveborn
Deliver-single stillborn
Deliver-twins, both live
Del-twins, 1 nb, 1 sb
Deliver-twins, both sb
Del-mult birth, all live
Del-mult brth, some live
Del-mult birth, all sb
Outcome of delivery NOS
Screening-chromosom anom
Screen-alphafetoprotein
Screen by amniocent NEC
Scr fetl malfrm-ultrasnd
Screen-fetal retardation
Screen-isoimmunization
Antenatal screen strep b
Scrn fetal anatmc survey
Scrn risk preterm labor
Antenatal screening NEC
Antenatal screening NOS
Prsc ntrutr cntrcptv dvc
Asympt postmeno status
Prphylct orgn rmvl ovary
Fit/adj breast pros/impl
Egg donor NEC
Egg donor age <35 anon
Egg donor age <35 desig
Egg donor age 35+ anon
October 2009
Diagnoses allowed for females only
V5974
V616
V617
V6701
V7231
V7232
V7240
V7241
V7242
V7611
V762
V7646
V7647
V824
V8402
V8404
V8801
V8802
V8803
V8901
V8902
V8903
V8904
V8905
V8909
Egg donor age 35+ desig
Illegitimate pregnancy
Unwanted pregnancy NEC
Follow-up vag pap smear
Routine gyn examination
Pap smear confirmation
Pregnancy test unconfirm
Pregnancy test negative
Pregnancy test-positive
Screen mammogram hi risk
Screen mal neop-cervix
Screen malig neop-ovary
Screen malig neop-vagina
Mat pstntl scr-chrm anom
Genetc sus mal neo ovary
Genetc susc mal neo endo
Acq absnce cervix/uterus
Acq ab ut remn cerv stmp
Acq absnc cerv/remain ut
Sus amntc cav/mem nt fnd
Sus placentl prob nt fnd
Sus fetal anomaly nt fnd
Sus fetal growth not fnd
Sus cervcl shortn nt fnd
Oth sus mat/ftl nt fnd
October 2009
Edit code lists 1.31
Procedures allowed for females only
6501
6509
6511
6512
6513
6514
6519
6521
6522
6523
6524
6525
6529
6531
6539
6541
6549
6551
6552
6553
6554
6561
6562
6563
6564
6571
6572
6573
6574
6575
6576
6579
6581
6589
6591
6592
6593
6594
6595
6599
6601
6602
6611
6619
6621
6622
6629
6631
6632
6639
664
6651
6652
6661
6662
6663
6669
6671
6672
6673
6674
6679
668
6691
6692
Laparoscopic oophorotomy
Other oophorotomy
Ovarian aspirat biopsy
Ovarian biopsy NEC
Lap biopsy of ovary
Oth lap dx proc ovaries
Ovarian dx procedure NEC
Ovarian cyst marsupializ
Ovarian wedge resection
Lap marsup ovarian cyst
Lap wedge resect ovary
Oth lap loc exc dest ova
Local destr ova les NEC
Lap unilat oophorectomy
Oth unilat oophorectomy
Lap uni salpingo-oophor
Oth uni salpingo-oophor
Oth remove both ovaries
Oth remove remain ovary
Lap remove both ovaries
Lap remove remain ovary
Oth remove ovaries/tubes
Oth remove rem ova/tube
Lap remove ovaries/tubes
Lap remove rem ova/tube
Oth simple suture ovary
Oth reimplant of ovary
Oth salpingo-oophoroplas
Lap simple suture ovary
Lap reimplant of ovary
Lap salpingo-oophoroplas
Repair of ovary NEC
Lap adhesiolys ova/tube
Adhesiolysis ovary/tube
Aspiration of ovary
Transplantation of ovary
Manual rupt ovarian cyst
Ovarian denervation
Ovarian torsion release
Ovarian operation NEC
Salpingotomy
Salpingostomy
Fallopian tube biopsy
Fallop tube dx proc NEC
Bilat endosc crush tube
Bilat endosc divis tube
Bilat endos occ tube NEC
Bilat tubal crushing NEC
Bilat tubal division NEC
Bilat tubal destruct NEC
Total unilat salpingect
Remove both fallop tubes
Remove solitary fal tube
Destroy fallop tube les
Remov tube & ectop preg
Bilat part salpingec NOS
Partial salpingectom NEC
Simpl suture fallop tube
Salpingo-oophorostomy
Salpingo-salpingostomy
Salpingo-uterostomy
Fallop tube repair NEC
Fallopian tube insufflat
Fallopian tube aspirat
Unilat fallop tube destr
1.32 Definitions of Medicare Code Edits
6693
6694
6695
6696
6697
6699
670
6711
6712
6719
672
6731
6732
6733
6739
674
6751
6759
6761
6762
6769
680
6811
6812
6813
6814
6815
6816
6819
6821
6822
6823
6829
6831
6839
6841
6849
6851
6859
6861
6869
6871
6879
688
689
6901
6902
6909
6919
6921
6922
6923
6929
693
6941
6942
6949
6951
6952
6959
696
697
6991
6992
6993
Impl fallop tube prosth
Remov fallop tube prosth
Blow therapeut into tube
Fallopian tube dilation
Bury fimbriae in uterus
Fallopian tube op NEC
Cervical canal dilation
Endocervical biopsy
Cervical biopsy NEC
Cervical dx procedur NEC
Conization of cervix
Cervical cyst marsupial
Cervical les cauterizat
Cervical les cryotherapy
Cervical les destruc NEC
Amputation of cervix
Transab cerclage cervix
Oth rep int cervical os
Suture cervical lacerat
Cervical fistula repair
Cervical repair NEC
Hysterotomy
Digital exam of uterus
Hysteroscopy
Open uterine biopsy
Open uterine ligament bx
Clos uterine ligament bx
Closed uterine biopsy
Uterus/adnex dx proc NEC
Endomet synechiae divis
Incision uterine septum
Endometrial ablation
Uterine les destruct NEC
Lap scervic hysterectomy
Subtotl abd hyst NEC/NOS
Lap total abdominal hyst
Total abd hyst NEC/NOS
Lap ast vag hysterectomy
Vag hysterectomy NEC/NOS
Lap radical abdomnl hyst
Radical abd hyst NEC/NOS
Lap radical vaginal hyst
Radical vag hyst NEC/NOS
Pelvic evisceration
Hysterectomy NEC/NOS
D & C for preg terminat
D & C post delivery
D & C NEC
Destruc uter support NEC
Interposit op uterin lig
Uterine suspension NEC
Vag repair invers uterus
Uterus/adnexa repair NEC
Paracerv uterine denerv
Suture uterine lacerat
Closure uterine fistula
Uterine repair NEC
Aspirat curet-preg termi
Aspirat curet-post deliv
Aspir curett uterus NEC
Menstrual extraction
Insertion of iud
Insert uterine device
Artificial insemination
Insertion of laminaria
October 2009
Procedures allowed for females only
6994
6995
6996
6997
6998
6999
700
7011
7012
7013
7014
7021
7022
7023
7024
7029
7031
7032
7033
704
7050
7051
7052
7053
7054
7055
7061
7062
7071
7072
7073
7074
7075
7076
7077
7078
7079
708
7091
7092
7093
7094
7095
7101
7109
7111
7119
7121
7122
7123
7124
7129
713
714
715
7161
7162
7171
7172
7179
718
719
720
721
7221
7229
7231
7239
Man replace invert uter
Incision of cervix
Remove cervical cerclage
Remove penetrat cerv FB
Uterine support op NEC
Uterine operation NEC
Culdocentesis
Hymenotomy
Culdotomy
Intralum vag adhesiolys
Vaginotomy NEC
Vaginoscopy
Culdoscopy
Cul-de-sac biopsy
Vaginal biopsy
Vagin/cul-de-sac dx NEC
Hymenectomy
Excis cul-de-sac lesion
Excision vaginal lesion
Vaginal obliteration
Cystocel/rectocel repair
Cystocele repair
Rectocele repair
Cysto & recto w grf/pros
Rep cystocel w grft/pros
Rep rectocele w grf/pros
Vaginal construction
Vaginal reconstruction
Suture vagina laceration
Repair colovagin fistula
Repair rectovag fistula
Rep vaginoent fistul NEC
Repair vag fistula NEC
Hymenorrhaphy
Vaginal suspens & fixat
Vag susp/fix w grft/pros
Vaginal repair NEC
Vaginal vault obliterat
Vaginal operation NEC
Cul-de-sac operation NEC
Cul-de-sac grf/pros NEC
Insert biological graft
Insert synth graft/prost
Vulvar adhesiolysis
Incis vulva/perineum NEC
Vulvar biopsy
Vulvar diagnos proc NEC
Percutan bartholin aspir
Incise bartholin's gland
Bartholin gland marsup
Destruc bartholin gland
Bartholin's gland op NEC
Local vulvar excis NEC
Operations on clitoris
Radical vulvectomy
Unilateral vulvectomy
Bilateral vulvectomy
Suture vulvar laceration
Repair vulvar fistula
Vulvar/perin repair NEC
Other vulvar operations
Other female genital ops
Low forceps operation
Low forceps w episiotomy
Mid forceps w episiotomy
Mid forceps op NEC
High forceps w episiot
High forceps op NEC
October 2009
724
7251
7252
7253
7254
726
7271
7279
728
729
7301
7309
731
7321
7322
733
734
7351
7359
736
738
7391
7392
7393
7394
7399
740
741
742
743
744
7491
7499
750
751
752
7531
7532
7533
7534
7535
7536
7537
7538
754
7550
7551
7552
7561
7562
7569
757
758
7591
7592
7593
7594
7599
8781
8782
8783
8784
8785
8789
8846
8878
8926
9141
Forceps rotat fetal head
Part brch extrac w forcp
Part breech extract NEC
Tot brch extrac w forcep
Tot breech extrac NEC
Forceps-aftercoming head
Vacuum ext del w episiot
Vacuum extract del NEC
Instrument delivery NEC
Instrument delivery NOS
Induct labor-rupt memb
Artif rupt membranes NEC
Surg induct labor NEC
Int/comb version no extr
Int/comb version w extr
Failed forceps
Medical induction labor
Manual rotat fetal head
Manual assist deliv NEC
Episiotomy
Fetal ops-facilitate del
Ext version-assist deliv
Replace prolapsed cord
Incis cx to assist deliv
Pubiotomy to assist del
Ops assisting deliv NEC
Classical c-section
Low cervical c-section
Extraperitoneal c-sect
Rem extratub ectop preg
Cesarean section NEC
Hysterotomy to termin pg
Cesarean section NOS
Intra-amnion inj for ab
Diagnostic amniocentesis
Intrauterine transfusion
Amnioscopy
Fetal ekg
Fetal blood sample/bx
Other fetal monitoring
Dx proc fetus/amnion NEC
Correction fetal defect
Amnioinfusion
Fetal pulse oximetry
Manual removal-placenta
Repair ob lac uterus NOS
Repair ob lacerat cervix
Repair ob lac corp uteri
Repair ob lac blad/ureth
Repair ob lac rect/anus
Repair ob laceration NEC
Manual explor uterus p/p
Ob tamponade uterus/vag
Evac ob inc hemat perin
Evac ob hemat vulva/vag
Surg corr invert uterus
Man replac invert uterus
Obstetric operation NEC
X-ray of gravid uterus
Gas hysterosalpingogram
Dye hysterosalpingogram
Percutaneous hysterogram
Tube & uterus x-ray NEC
Female genital x-ray NEC
Contrast placentogram
Dx ultrasound-grav uter
Gynecologic examination
Bact smear-female genit
Edit code lists 1.33
Procedures allowed for females only
9142
9143
9144
9145
9146
9149
9217
9614
9615
9616
9617
9618
9644
9724
9725
9726
9771
9772
9773
9774
9775
9816
9817
9823
9998
Culture-female genital
C & s-female genital
Parasitology-female gen
Toxicology-female genit
Cell blk/pap-female gen
Micro exam-femal gen NEC
Placental scan
Vaginal packing
Vaginal mold insertion
Other vaginal dilation
Vag diaphragm insertion
Oth vagin pessary insert
Vaginal douche
Replace vag diaphragm
Replace vaginal pessary
Replace vag/vulv packing
Removal iud
Remov intrauterine pack
Remov vaginal diaphragm
Removal oth vag pessary
Remov vag/vulv packing
Remov intralum uter FB
Remov intralum vag FB
Removal vulvar FB
Milk extraction
1.34 Definitions of Medicare Code Edits
October 2009
Diagnoses allowed for males only
01640
01641
01642
01643
01644
01645
01646
01650
01651
01652
01653
01654
01655
01656
05413
0720
09812
09813
09814
09832
09833
09834
13103
1750
1759
185
1860
1869
1871
1872
1873
1874
1875
1876
1877
1878
1879
2144
2220
2221
2222
2223
2224
2228
2229
2334
2335
2336
2364
2365
2366
2570
2571
2579
30274
30275
4564
60000
60001
60010
60011
60020
60021
6003
60090
TB epididymis-unspec
TB epididymis-no exam
TB epididymis-exam unkn
TB epididymis-micro dx
TB epididymis-cult dx
TB epididymis-histo dx
TB epididymis-oth test
TB male genit NEC-unspec
TB male gen NEC-no exam
TB male gen NEC-ex unkn
TB male gen NEC-micro dx
TB male gen NEC-cult dx
TB male gen NEC-histo dx
TB male gen NEC-oth test
Herpetic infect of penis
Mumps orchitis
Gc prostatitis (acute)
Gc orchitis (acute)
Gc sem vesiculit (acute)
Gc prostatitis, chronic
Gc orchitis, chronic
Gc sem vesiculitis, chr
Trichomonal prostatitis
Mal neo male nipple
Mal neo male breast NEC
Malign neopl prostate
Mal neo undescend testis
Malig neo testis NEC
Malign neopl prepuce
Malig neo glans penis
Malig neo penis body
Malig neo penis NOS
Malig neo epididymis
Mal neo spermatic cord
Malign neopl scrotum
Mal neo male genital NEC
Mal neo male genital NOS
Lipoma spermatic cord
Benign neoplasm testis
Benign neoplasm penis
Benign neoplasm prostate
Benign neo epididymis
Benign neoplasm scrotum
Ben neo male genital NEC
Ben neo male genital NOS
Ca in situ prostate
Ca in situ penis
Ca in situ male gen NEC
Unc behav neo testis
Unc behav neo prostate
Unc behav neo male NEC
Testicular hyperfunction
Postablat testic hypofun
Testicular dysfunct NOS
Male orgasmic disorder
Premature ejaculation
Scrotal varices
BPH w/o urinary obs/LUTS
BPH w urinary obs/LUTS
Nod prostate w/o ur obst
Nod prostate w ur obst
BPH loc w/o ur obs/LUTS
BPH loc w urin obs/LUTS
Cyst of prostate
BPH NOS w/o ur obs/LUTS
October 2009
60091
6010
6011
6012
6013
6014
6018
6019
6020
6021
6022
6023
6028
6029
6030
6031
6038
6039
6040
60490
60491
60499
605
6060
6061
6068
6069
6070
6071
6072
6073
60781
60782
60783
60784
60785
60789
6079
6080
6081
60820
60821
60822
60823
60824
6083
6084
60881
60882
60883
60884
60885
60886
60887
60889
6089
75251
75252
75261
75262
75263
75264
75265
75269
75281
BPH NOS w ur obs/LUTS
Acute prostatitis
Chronic prostatitis
Abscess of prostate
Prostatocystitis
Prostatitis in oth dis
Prostatic inflam dis NEC
Prostatitis NOS
Calculus of prostate
Prostatic congest/hemorr
Atrophy of prostate
Dysplasia of prostate
Prostatic disorders NEC
Prostatic disorder NOS
Encysted hydrocele
Infected hydrocele
Hydrocele NEC
Hydrocele NOS
Orchitis with abscess
Orchitis/epididymit NOS
Orchitis in oth disease
Orchitis/epididymit NEC
Redun prepuce & phimosis
Azoospermia
Oligospermia
Male infertility NEC
Male infertility NOS
Leukoplakia of penis
Balanoposthitis
Inflam dis, penis NEC
Priapism
Balanitis xerotica oblit
Vascular disorder, penis
Edema of penis
Impotence, organic orign
Peyronie's disease
Disorder of penis NEC
Disorder of penis NOS
Seminal vesiculitis
Spermatocele
Torsion of testis NOS
Extravag tors sperm cord
Intravag tors sperm cord
Torsion appendix testis
Torsion appy epididymis
Atrophy of testis
Male gen inflam dis NEC
Male gen dis in oth dis
Hematospermia
Male gen vascul dis NEC
Chylocele, tunic vaginal
Stricture, male gen orgn
Edema, male genital orgn
Retrograde ejaculation
Male genital dis NEC
Male genital dis NOS
Undescended testis
Retractile testis
Hypospadias
Epispadias
Congenital chordee
Micropenis
Hidden penis
Penile anomalies NEC
Scrotal transposition
Edit code lists 1.35
Diagnoses allowed for males only
7587
78832
79093
7922
8780
8781
8782
8783
9393
95913
V1045
V1046
V1047
V1048
V1049
V1361
V2634
V2635
V2639
V2652
V502
V7644
V7645
V8403
Klinefelter's syndrome
Stress incontinence male
Elvtd prstate spcf antgn
Abn findings-semen
Open wound of penis
Open wound penis-compl
Opn wound scrotum/testes
Opn wnd scrot/test-compl
Foreign body penis
Fx corpus cavrnosm penis
Hx-male genit malig NOS
Hx-prostatic malignancy
Hx-testicular malignancy
Hx-epididymis malignancy
Hx-male genit malig NEC
Hx-hypospadius
Male genetc test dis car
Test male part hab abort
Male genetic test NEC
Vasectomy status
Routine circumcision
Scrn malig neop-prostate
Screen malig neop-testis
Genetc sus mal neo prost
1.36 Definitions of Medicare Code Edits
October 2009
Procedures allowed for males only
600
6011
6012
6013
6014
6015
6018
6019
6021
6029
603
604
605
6061
6062
6069
6071
6072
6073
6079
6081
6082
6091
6092
6093
6094
6095
6096
6097
6099
610
6111
6119
612
613
6141
6142
6149
6191
6192
6199
620
6211
6212
6219
622
623
6241
6242
625
6261
6269
627
6291
6292
6299
6301
6309
Incision of prostate
Closed prostatic biopsy
Open prostatic biopsy
Clos seminal vesicles bx
Open seminal vesicles bx
Periprostatic biopsy
Prostatic dx proced NEC
Semin ves dx proced NEC
Transureth prostatectomy
Oth transureth prostatec
Suprapubic prostatectomy
Retropubic prostatectomy
Radical prostatectomy
Los excis prostatic les
Perineal prostatectomy
Prostatectomy NEC
Percut semin ves aspirat
Seminal vesicle incision
Seminal vesicle excision
Seminal vesicle op NEC
Periprostatic incision
Periprostatic excision
Percut prostatic aspirat
Injection into prostate
Repair of prostate
Control prostate hemorr
Trans bal dil pros ureth
Tu destr prostate by mt
Oth tu destr pros - rt
Prostatic operation NEC
Scrotum & tunica i & d
Scrotum & tunica biopsy
Scrot/tunica dx proc NEC
Excision of hydrocele
Scrotal les destruction
Suture scrotal lacerat
Scrotal fistula repair
Scrotum/tunic repair NEC
Percut tunica aspiration
Excision tunica les NEC
Scrotum & tunica op NEC
Incision of testes
Closed testicular biopsy
Open testicular biopsy
Testes dx procedure NEC
Testicular les destruct
Unilateral orchiectomy
Remove both testes
Remove solitary testis
Orchiopexy
Suture testicular lacer
Testicular repair NEC
Insert testicular prosth
Aspiration of testes
Injection into testes
Testicular operation NEC
Spermatic cord/vas biops
Spermat cord/vas dx NEC
October 2009
631
632
633
634
6351
6352
6353
6359
636
6370
6371
6372
6373
6381
6382
6383
6384
6385
6389
6391
6392
6393
6394
6395
6399
640
6411
6419
642
643
6441
6442
6443
6444
6445
6449
645
6491
6492
6493
6494
6495
6496
6497
6498
6499
8791
8792
8793
8794
8795
8799
9824
9994
9995
9996
Exc spermatic varicocele
Excise epididymis cyst
Excise cord/epid les NEC
Epididymectomy
Suture cord & epid lacer
Reduction torsion testes
Transplant spermat cord
Cord & epidid repair NEC
Vasotomy
Male sterilization NOS
Ligation of vas deferens
Spermatic cord ligation
Vasectomy
Suture vas & epidid lac
Postop vas reconstruct
Epididymovasostomy
Removal vas ligature
Remov vas deferens valve
Vas & epididy repair NEC
Spermatocele aspiration
Epididymotomy
Spermatic cord incision
Sperm cord adhesiolysis
Insert valve in vas def
Cord/epid/vas ops NEC
Circumcision
Penile biopsy
Penile diagnost proc NEC
Local excis penile les
Amputation of penis
Suture penile laceration
Release of chordee
Construction of penis
Reconstruction of penis
Replantation of penis
Penile repair NEC
Sex transformat op NEC
Dorsal/lat slit prepuce
Incision of penis
Division of penile adhes
Fit ext penile prosthes
Ins noninfl penis prosth
Remove int penile prosth
Ins inflate penis prosth
Penile operation NEC
Male genital op NEC
Contr semin vesiculogram
Prostat/sem ves xray NEC
Contrast epididymogram
Contrast vasogram
Epididymis/vas x-ray NEC
Male genital x-ray NEC
Removal scrotal/penis FB
Prostatic massage
Stretching of foreskin
Sperm collection
Edit code lists 1.37
6. Manifestation code as
principal diagnosis
6. Manifestation code as principal diagnosis
Manifestation codes describe the manifestation of an underlying disease, not the disease itself, and therefore should not be used as a
principal diagnosis.
The following list contains ICD-9-CM diagnoses with corresponding
English descriptions identified as manifestation codes.
Manifestations not allowed as principal diagnosis
2842
28952
28983
29410
29411
3207
3210
3211
3212
3213
3214
3218
32301
32302
3231
3232
32341
32342
32361
32362
32363
32371
32372
32701
32702
32714
32715
32726
32727
32737
32744
3302
3303
3317
3344
3362
3363
3371
34121
34710
34711
3571
3572
3573
3574
3581
3595
3596
36201
36202
36203
36204
36205
Myelophthisis
Splenic sequestration
Myelofibrosis
Dementia w/o behav dist
Dementia w behavior dist
Mening in oth bact dis
Cryptococcal meningitis
Mening in oth fungal dis
Mening in oth viral dis
Trypanosomiasis meningit
Meningit d/t sarcoidosis
Mening in oth nonbac dis
Enceph/encephmye oth dis
Myelitis-oth viral dis
Rickettsial encephalitis
Protozoal encephalitis
Enceph/myelitis-oth inf
Myelitis d/t oth infect
Inf ac dis encephalomyel
Postinf encephalitis NEC
Postinfectious myelitis
Toxic encph & encephlomy
Toxic myelitis
Insomnia in other dis
Insomnia dt mental disor
Hypersomnia in other dis
Hypersom dt mental disor
Sleep hypovent oth dis
Cntrl sleep apnea ot dis
Circadian rhym oth dis
Parasomnia oth diseases
Cereb degen in lipidosis
Cerb deg chld in oth dis
Cereb degen in oth dis
Cerebel atax in oth dis
Comb deg cord in oth dis
Myelopathy in oth dis
Aut neuropthy in oth dis
Acute myelitis oth cond
Narclpsy w/o cat oth dis
Narcolepsy w cat oth dis
Neurpthy in col vasc dis
Neuropathy in diabetes
Neuropathy in malig dis
Neuropathy in other dis
Myasthenia in oth dis
Myopathy in endocrin dis
Infl myopathy in oth dis
Diabetic retinopathy NOS
Prolif diab retinopathy
Nonprolf db retnoph NOS
Mild nonprolf db retnoph
Mod nonprolf db retinoph
1.38 Definitions of Medicare Code Edits
36206
36207
36271
36272
36411
36544
36641
36642
36643
36644
37044
37105
37215
37231
37233
3734
3735
3736
37451
37613
37621
37622
38013
38015
38202
4200
4211
4220
42491
4257
4258
44381
45620
45621
4841
4843
4845
4846
4847
4848
5161
5171
5172
5173
5178
52510
52511
52512
52513
52519
5670
5731
5732
Sev nonprolf db retinoph
Diabetic macular edema
Ret dystrph in lipidoses
Ret dystrph in syst dis
Chr iridocyl in oth dis
Glaucoma w systemic synd
Diabetic cataract
Tetanic cataract
Myotonic cataract
Cataract w syndrome NEC
Keratitis in exanthema
Phthisical cornea
Parasitic conjunctivitis
Rosacea conjunctivitis
Mucocutan dis conjunctiv
Infect derm lid w deform
Infec dermatitis lid NEC
Parasitic infest eyelid
Xanthelasma
Parasite infest, orbit
Thyrotoxic exophthalmos
Exophthalm ophthalmopleg
Ac infect extern ear NEC
Chr mycot otitis externa
Ac supp OM in oth dis
Ac pericardit in oth dis
Ac endocardit in oth dis
Ac myocardit in oth dis
Endocarditis in oth dis
Metabolic cardiomyopathy
Cardiomyopath in oth dis
Angiopathy in other dis
Bleed esoph var oth dis
Esoph varice oth dis NOS
Pneum w cytomeg incl dis
Pneumonia in whoop cough
Pneumonia in anthrax
Pneum in aspergillosis
Pneum in oth sys mycoses
Pneum in infect dis NEC
Idio pulm hemosiderosis
Rheumatic pneumonia
Syst sclerosis lung dis
Acute chest syndrome
Lung involv in oth dis
Acq absence of teeth NOS
Loss of teeth d/t trauma
Loss teeth d/t peri dis
Loss of teeth d/t caries
Loss of teeth NEC
Peritonitis in infec dis
Hepatitis in viral dis
Hepatitis in oth inf dis
October 2009
Manifestations not allowed as principal diagnosis
58081
58181
58281
58381
59081
5954
59801
6014
60491
60881
61611
61651
6281
71110
71111
71112
71113
71114
71115
71116
71117
71118
71119
71120
71121
71122
71123
71124
71125
71126
71127
71128
71129
71130
71131
71132
71133
71134
71135
71136
71137
71138
71139
71140
71141
71142
71143
71144
71145
71146
71147
71148
71149
71150
71151
71152
71153
71154
71155
71156
71157
71158
71159
71160
71161
71162
71163
71164
Ac nephritis in oth dis
Nephrotic syn in oth dis
Chr nephritis in oth dis
Nephritis NOS in oth dis
Pyelonephrit in oth dis
Cystitis in oth dis
Ureth strict:oth infect
Prostatitis in oth dis
Orchitis in oth disease
Male gen dis in oth dis
Vaginitis in oth disease
Vulvar ulcer in oth dis
Infertil-pituitary orig
Reiter arthritis-unspec
Reiter arthritis-shlder
Reiter arthritis-up/arm
Reiter arthritis-forearm
Reiter arthritis-hand
Reiter arthritis-pelvis
Reiter arthritis-l/leg
Reiter arthritis-ankle
Reiter arthritis NEC
Reiter arthritis-mult
Behcet arthritis-unspec
Behcet arthritis-shlder
Behcet arthritis-up/arm
Behcet arthritis-forearm
Behcet arthritis-hand
Behcet arthritis-pelvis
Behcet arthritis-l/leg
Behcet arthritis-ankle
Behcet arthritis NEC
Behcet arthritis-mult
Dysenter arthrit-unspec
Dysenter arthrit-shlder
Dysenter arthrit-up/arm
Dysenter arthrit-forearm
Dysenter arthrit-hand
Dysenter arthrit-pelvis
Dysenter arthrit-l/leg
Dysenter arthrit-ankle
Dysenter arthrit NEC
Dysenter arthrit-mult
Bact arthritis-unspec
Bact arthritis-shlder
Bact arthritis-up/arm
Bact arthritis-forearm
Bact arthritis-hand
Bact arthritis-pelvis
Bact arthritis-l/leg
Bact arthritis-ankle
Bact arthritis NEC
Bact arthritis-mult
Viral arthritis-unspec
Viral arthritis-shlder
Viral arthritis-up/arm
Viral arthritis-forearm
Viral arthritis-hand
Viral arthritis-pelvis
Viral arthritis-l/leg
Viral arthritis-ankle
Viral arthritis NEC
Viral arthritis-mult
Mycotic arthritis-unspec
Mycotic arthritis-shlder
Mycotic arthritis-up/arm
Mycotic arthrit-forearm
Mycotic arthritis-hand
October 2009
71165
71166
71167
71168
71169
71170
71171
71172
71173
71174
71175
71176
71177
71178
71179
71180
71181
71182
71183
71184
71185
71186
71187
71188
71189
71210
71211
71212
71213
71214
71215
71216
71217
71218
71219
71220
71221
71222
71223
71224
71225
71226
71227
71228
71229
71230
71231
71232
71233
71234
71235
71236
71237
71238
71239
7130
7131
7132
7133
7134
7135
7136
7137
7138
72081
72701
73070
73071
Mycotic arthritis-pelvis
Mycotic arthritis-l/leg
Mycotic arthritis-ankle
Mycotic arthritis NEC
Mycotic arthritis-mult
Helminth arthrit-unspec
Helminth arthrit-shlder
Helminth arthrit-up/arm
Helminth arthrit-forearm
Helminth arthrit-hand
Helminth arthrit-pelvis
Helminth arthrit-l/leg
Helminth arthrit-ankle
Helminth arthrit NEC
Helminth arthrit-mult
Inf arthritis NEC-unspec
Inf arthritis NEC-shlder
Inf arthritis NEC-up/arm
Inf arthrit NEC-forearm
Inf arthritis NEC-hand
Inf arthritis NEC-pelvis
Inf arthritis NEC-l/leg
Inf arthritis NEC-ankle
Inf arthrit NEC-oth site
Inf arthritis NEC-mult
Dicalc phos cryst-unspec
Dicalc phos cryst-shlder
Dicalc phos cryst-up/arm
Dicalc phos crys-forearm
Dicalc phos cryst-hand
Dicalc phos cryst-pelvis
Dicalc phos cryst-l/leg
Dicalc phos cryst-ankle
Dicalc phos cry-site NEC
Dicalc phos cryst-mult
Pyrophosph cryst-unspec
Pyrophosph cryst-shlder
Pyrophosph cryst-up/arm
Pyrophosph cryst-forearm
Pyrophosph cryst-hand
Pyrophosph cryst-pelvis
Pyrophosph cryst-l/leg
Pyrophosph cryst-ankle
Pyrophos cryst-site NEC
Pyrophos cryst-mult
Chondrocalcin NOS-unspec
Chondrocalcin NOS-shlder
Chondrocalcin NOS-up/arm
Chondrocalc NOS-forearm
Chondrocalcin NOS-hand
Chondrocalcin NOS-pelvis
Chondrocalcin NOS-l/leg
Chondrocalcin NOS-ankle
Chondrocalc NOS-oth site
Chondrocalcin NOS-mult
Arthrop w endocr/met dis
Arthrop w noninf GI dis
Arthropath w hematol dis
Arthropathy w skin dis
Arthropathy w resp dis
Arthropathy w nerve dis
Arthrop w hypersen react
Arthrop w system dis NEC
Arthrop w oth dis NEC
Spondylopathy in oth dis
Synovitis in oth dis
Polio osteopathy-unspec
Polio osteopathy-shlder
Edit code lists 1.39
Manifestations not allowed as principal diagnosis
73072
73073
73074
73075
73076
73077
73078
73079
73080
73081
73082
73083
73084
73085
73086
73087
73088
73089
7311
7318
73740
73741
73742
73743
7740
77431
7745
78061
78552
Polio osteopathy-up/arm
Polio osteopathy-forearm
Polio osteopathy-hand
Polio osteopathy-pelvis
Polio osteopathy-l/leg
Polio osteopathy-ankle
Polio osteopathy NEC
Polio osteopathy-mult
Bone infect NEC-unspec
Bone infect NEC-shlder
Bone infect NEC-up/arm
Bone infect NEC-forearm
Bone infect NEC-hand
Bone infect NEC-pelvis
Bone infect NEC-l/leg
Bone infect NEC-ankle
Bone infect NEC-oth site
Bone infect NEC-mult
Osteitis def in oth dis
Bone involv in oth dis
Spin curv NOS in oth dis
Kyphosis in oth dis
Lordosis in oth dis
Scoliosis in oth dis
Perinat jaund-hered anem
Neonat jaund in oth dis
Perinatal jaundice NEC
Fever in other diseases
Septic shock
1.40 Definitions of Medicare Code Edits
October 2009
7.7.
Non-specific
principal
diagnosis
Non-specific
principal
diagnosis
8. Questionable admission
Effective 10/01/07, the non-specific principal diagnosis edit was discontinued and will appear for claims processed using MCE version
2.0-23.0 only.
Some diagnoses are not usually sufficient justification for admission
to an acute care hospital. For example, if a patient is given code 4011
for benign hypertension, then the patient would have a questionable
admission, since benign hypertension is not normally sufficient justification for admission to a hospital.
The following list contains diagnosis codes with corresponding
English descriptions identified as questionable admission when used
as a principal diagnosis.
Questionable admissions - principal diagnosis only
25000
27800
3804
4011
4262
4263
4264
79093
7962
9999
V08
V5331
V5332
V5339
DMII wo cmp nt st uncntr
Obesity NOS
Impacted cerumen
Benign hypertension
Left bb hemiblock
Left bb block NEC
Rt bundle branch block
Elvtd prstate spcf antgn
Elev bl pres w/o hypertn
Complic med care NEC/NOS
Asymp hiv infectn status
Ftng cardiac pacemaker
Ftng autmtc dfibrillator
Ftng oth cardiac device
October 2009
Edit code lists 1.41
9.
Unacceptable
principal
9. Unacceptable
principal
diagnosis
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.
There are a few usually unacceptable principal diagnosis codes that
are considered “acceptable” when a secondary diagnosis is also coded
on the record. If no secondary diagnosis is present for this subset of
codes, the message REQUIRES SECONDARY DX will appear.
The following pages contain a list of codes with corresponding
English descriptions identified as unacceptable when entered as principal diagnosis.
➤
Note: Codes that require a secondary diagnosis are indicated
with an asterisk (*).
1.42 Definitions of Medicare Code Edits
October 2009
Unacceptable principal diagnoses
1992
23877
27950
27951
27952
27953
3051
3533
3708
4142
4143
41512
4233
4404
449
6113
69550
69551
69552
69553
69554
69555
69556
69557
69558
69559
78951
7981
7982
7989
V010
V011
V012
V013
V014
V015
V016
V0181
V0189
V019
V020
V021
V022
V023
V024
V0251
V0252
V0253
V0254
V0259
V0260
V0261
V0262
V0269
V027
V028
V029
V030
V031
V032
V033
V034
V035
V036
V037
Malig neopl-transp organ
Post tp lymphprolif dis
Graft-versus-host NOS
Ac graft-versus-host dis
Chronc graft-vs-host dis
Ac on chrn grft-vs-host
Tobacco use disorder
Thoracic root lesion NEC
Keratitis NEC
Chr tot occlus cor artry
Cor ath d/t lpd rch plaq
Septic pulmonary embolsm
Cardiac tamponade
Chr tot occl art extrem
Septic arterial embolism
Fat necrosis of breast
Exfol d/t eryth <10% bdy
Exfl d/t eryth 10-19 bdy
Exfl d/t eryth 20-29 bdy
Exfl d/t eryth 30-39 bdy
Exfl d/t eryth 40-49 bdy
Exfl d/t eryth 50-59 bdy
Exfl d/t eryth 60-69 bdy
Exfl d/t eryth 70-79 bdy
Exfl d/t eryth 80-89 bdy
Exfl d/t eryth >=90% bdy
Malignant ascites
Instantaneous death
Death within 24 hr sympt
Unattended death
Cholera contact
Tuberculosis contact
Poliomyelitis contact
Smallpox contact
Rubella contact
Rabies contact
Venereal dis contact
Contact/exposure-anthrax
Communic dis contact NEC
Communic dis contact NOS
Cholera carrier
Typhoid carrier
Amebiasis carrier
GI pathogen carrier NEC
Diphtheria carrier
Group b streptoc carrier
Streptococus carrier NEC
Meth susc Staph carrier
Meth resis Staph carrier
Bacteria dis carrier NEC
Viral hep carrier NOS
Hepatitis B carrier
Hepatitis C carrier
Viral hep carrier NEC
Gonorrhea carrier
Venereal dis carrier NEC
Carrier NEC
Vaccin for cholera
Vacc-typhoid-paratyphoid
Vaccin for tuberculosis
Vaccin for plague
Vaccin for tularemia
Vaccin for diphtheria
Vaccin for pertussis
Tetanus toxoid inoculat
October 2009
V0381
V0382
V0389
V039
V040
V041
V042
V043
V044
V045
V046
V047
V0481
V0482
V0489
V050
V051
V052
V053
V054
V058
V059
V060
V061
V062
V063
V064
V065
V066
V068
V069
V071
V072
V0731
V074
V0751
V0752
V0759
V079
V090
V091
V092
V093
V094
V0950
V0951
V096
V0970
V0971
V0980
V0981
V0990
V0991
V1000
V1001
V1002
V1003
V1004
V1005
V1006
V1007
V1009
V1011
V1012
V1020
V1021
V1022
V1029
Nd vac hmophlus inflnz b
Nd vac strptcs pneumni b
Nd other specf vacnation
Vaccin for bact dis NOS
Vaccin for poliomyelitis
Vaccin for smallpox
Vaccin for measles
Vaccin for rubella
Vaccin for yellow fever
Vaccin for rabies
Vaccin for mumps
Vaccin for common cold
Vaccin for influenza
Vaccination for RSV
Vaccn/inoc viral dis NEC
Arbovirus enceph vaccin
Vacc arboviral dis NEC
Vaccin for leishmaniasis
Need prphyl vc vrl hepat
Need prphyl vc varicella
Vaccin for disease NEC
Vaccin for singl dis NOS
Vaccin for cholera + tab
Vaccination for DTP-DTaP
Vaccin for dtp + tab
Vaccin for dtp + polio
Vac-measle-mumps-rubella
Vaccination for Td-DT
Nd vac strp pnumn/inflnz
Vac-dis combinations NEC
Vac-dis combinations NOS
Desensitiza to allergens
Prophylact immunotherapy
Prophylac fluoride admin
Hormone replace postmeno
Prophylactic use SERMs
Prophylact use aromatase
Prphyl ot agnt af estrgn
Prophylactic measure NOS
Inf mcrg rstn pncllins
Inf mcrg rstn b-lactam
Inf mcrg rstn macrolides
Inf mcrg rstn ttrcycln
Inf mcrg rstn amnglcsds
Inf mcr rst qn flr nt ml
Inf mcrg rstn qn flrq ml
Inf mcrg rstn sulfnmides
Inf mcr rst oth ag nt ml
Inf mcrg rstn oth ag mlt
Inf mcr rst ot drg nt ml
Inf mcrg rstn oth drg ml
Infc mcrg drgrst nt mult
Infc mcrg drgrst mult
Hx of GI malignancy NOS
Hx of tongue malignancy
Hx-oral/pharynx malg NEC
Hx-esophageal malignancy
Hx of gastric malignancy
Hx of colonic malignancy
Hx-rectal & anal malign
Hx of liver malignancy
Hx of GI malignancy NEC
Hx-bronchogenic malignan
Hx-tracheal malignancy
Hx-resp org malignan NOS
Hx-laryngeal malignancy
Hx-nose/ear/sinus malig
Hx-intrathoracic mal NEC
Edit code lists 1.43
Unacceptable principal diagnoses
V103
V1040
V1041
V1042
V1043
V1044
V1045
V1046
V1047
V1048
V1049
V1050
V1051
V1052
V1053
V1059
V1060
V1061
V1062
V1063
V1069
V1071
V1072
V1079
V1081
V1082
V1083
V1084
V1085
V1086
V1087
V1088
V1089
V1090
V1091
V110
V111
V112
V113
V118
V119
V1200
V1201
V1202
V1203
V1204
V1209
V121
V122
V123
V1240
V1241
V1242
V1249
V1250
V1251
V1252
V1253
V1254
V1259
V1260
V1261
V1269
V1270
V1271
V1272
V1279
V1300
Hx of breast malignancy
Hx-female genit malg NOS
Hx-cervical malignancy
Hx-uterus malignancy NEC
Hx of ovarian malignancy
Hx-female genit malg NEC
Hx-male genit malig NOS
Hx-prostatic malignancy
Hx-testicular malignancy
Hx-epididymis malignancy
Hx-male genit malig NEC
Hx-urinary malignan NOS
Hx of bladder malignancy
Hx of kidney malignancy
Hx malig renal pelvis
Hx-urinary malignan NEC
Hx of leukemia NOS
Hx of lymphoid leukemia
Hx of myeloid leukemia
Hx of monocytic leukemia
Hx of leukemia NEC
Hx-lymphosarcoma
Hx-hodgkin's disease
Hx-lymphatic malign NEC
Hx of bone malignancy
Hx-malig skin melanoma
Hx-skin malignancy NEC
Hx of eye malignancy
Hx of brain malignancy
Hx-malign nerve syst NEC
Hx of thyroid malignancy
Hx-endocrine malign NEC
Hx of malignancy NEC
Hx malig neoplasm NOS
Hx malig neuroendo tumor
Hx of schizophrenia
Hx of affective disorder
Hx of neurosis
Hx of alcoholism
Hx-mental disorder NEC
Hx-mental disorder NOS
Prsnl hst unsp nfct prst
Prsnl hst tuberculosis
Prsnl hst poliomyelitis
Personal histry malaria
Hx Methicln resist Staph
Prsnl hst oth nfct parst
Hx-nutrition deficiency
Hx-endocr/meta/immun dis
Hx-blood diseases
Hx nerv sys/snse org NOS
Hx benign neoplasm brain
Personl hx infection CNS
Hx nerv sys/snse org NEC
Hx-circulatory dis NOS
Hx-ven thrombosis/embols
Hx-thrombophlebitis
Hx sudden cardiac arrest
Hx TIA/stroke w/o resid
Hx-circulatory dis NEC
Hx resp system dis NOS
Prsnl hx recur pneumonia
Hx resp system dis NEC
Prsnl hst unspc dgstv ds
Prsnl hst peptic ulcr ds
Prsnl hst colonic polyps
Prsnl hst ot spf dgst ds
Prsnl hst urnr dsrd unsp
1.44 Definitions of Medicare Code Edits
V1301
V1302
V1303
V1309
V131
V1321
V1322
V1329
V133
V134
V1351
V1352
V1359
V1361
V1369
V137
V138
V139
V140
V141
V142
V143
V144
V145
V146
V147
V148
V149
V1501
V1502
V1503
V1504
V1505
V1506
V1507
V1508
V1509
V151
V1521
V1522
V1529
V153
V1541
V1542
V1549
V1551
V1552
V1559
V156
V157
V1580
V1581
V1582
V1583
V1584
V1585
V1586
V1587
V1588
V1589
V159
V160
V161
V162
V163
V1640
V1641
V1642
Prsnl hst urnr dsrd calc
Personal history UTI
Personl hx nephrotic syn
Prsn hst ot spf urn dsrd
Hx-trophoblastic disease
History-pre-term labor
Hx of cervical dysplasia
Hx-genital/obs dis NEC
Hx-skin/subcutan tis dis
Hx of arthritis
Hx pathological fracture
Hx stress fracture
Hx musculoskletl dis NEC
Hx-hypospadius
Hx-congenital malfor NEC
Hx-perinatal problems
Hx of diseases NEC
Hx of disease NOS
Hx-penicillin allergy
Hx-antibiot allergy NEC
Hx-sulfonamides allergy
Hx-anti-infect allergy
Hx-anesthetic allergy
Hx-narcotic allergy
Hx-analgesic allergy
Hx-vaccine allergy
Hx-drug allergy NEC
Hx-drug allergy NOS
Hx-peanut allergy
Hx-milk prod allergy
Hx-eggs allergy
Hx-seafood allergy
Hx-other food allergy
Hx-allergy insct/arachnd
Hx-latex allergy
Hx-radiogrphc dye allrgy
Hx-allergy NEC
Hx-major cardiovasc surg
Hx in utero proc in preg
Hx in utero proc fetus
Hx surgery to organs NEC
Hx of irradiation
Hx of physical abuse
Hx of emotional abuse
Psychological trauma NEC
Hx traumatic fracture
Hx traumatc brain injury
Hx injury NEC
Hx of poisoning
Hx of contraception
Hx failed mod sedation
Hx of past noncompliance
History of tobacco use
Hx underimmunizn status
Hx-contct/expos asbestos
Hx-cont/exps haz bdy fld
Hx-contact/exposure lead
Hx of ECMO
Personal history of fall
Hx-health hazards NEC
Hx-health hazard NOS
Family hx-gi malignancy
Fm hx-trach/bronchog mal
Fam hx-intrathoracic mal
Family hx-breast malig
Fm hx genital malig NOS
Fm hx ovary malignancy
Fm hx prostate malig
October 2009
Unacceptable principal diagnoses
V1643
V1649
V1651
V1652
V1659
V166
V167
V168
V169
V170
V171
V172
V173
V1741
V1749
V175
V176
V177
V1781
V1789
V180
V1811
V1819
V182
V183
V184
V1851
V1859
V1861
V1869
V187
V188
V189
V190
V191
V192
V193
V194
V195
V196
V197
V198
V201
V202
V2031
V2032
V210
V211
V212
V2130
V2131
V2132
V2133
V2134
V2135
V218
V219
V220
V221
V222
V230
V231
V232
V233
V2341
V2349
V235
V237
Fm hx testis malig
Fm hx genital malig NEC
Family hx-kidney malig
Fam hx-bladder malig
Fam hx-urinry malig NEC
Family hx-leukemia
Fam hx-lymph neoplas NEC
Family hx-malignancy NEC
Family hx-malignancy NOS
Fam hx-psychiatric cond
Family hx-stroke
Fam hx-neurolog dis NEC
Fam hx-ischem heart dis
Fam hx sudden card death
Fam hx-cardiovas dis NEC
Family hx-asthma
Fam hx-chr resp cond NEC
Family hx-arthritis
Family hx osteoporosis
Fam hx musculosk dis NEC
Fam hx-diabetes mellitus
Fam hx MEN syndrome
Fm hx endo/metab dis NEC
Family hx-anemia
Fam hx-blood disord NEC
Fam hx-mental retardat
Family hx colonic polyps
Fam hx digest disord NEC
Fam hx-polycystic kidney
Fam hx-kidney dis NEC
Family hx-gu disease NEC
Fm hx-infect/parasit dis
Fam hx genet dis carrier
Family hx-blindness
Family hx-eye disord NEC
Family hx-deafness
Family hx-ear disord NEC
Family hx-skin condition
Fam hx-congen anomalies
Family hx-allergic dis
Consanguinity
Family hx-condition NEC
Care of healthy chld NEC
Routin child health exam
Health supvsn nb <8 days
Health supv nb 8-28 days
Rapid childhood growth
Puberty
Adolescence growth NEC
Low birthwt status NOS
Low birthwt status <500g
Low birthwt 500-999g
Low birthwt 1000-1499g
Low birthwt 1500-1999g
Low birthwt 2000-2500g
Constit state in dev NEC
Constit state in dev NOS
Supervis normal 1st preg
Supervis oth normal preg
Preg state, incidental
Preg w hx of infertility
Preg w hx-trophoblas dis
Preg w hx of abortion
Grand multiparity
Preg w hx pre-term labor
Preg w poor obs hx NEC
Preg w poor reproduct hx
Insufficnt prenatal care
October 2009
V2381
V2382
V2383
V2384
V2385
V2386
V2389
V239
V241
V242
V2501
V2502
V2503
V2504
V2509
V251
V2540
V2541
V2542
V2543
V2549
V255
V258
V259
V261
V2621
V2622
V2629
V2631
V2632
V2633
V2634
V2635
V2639
V2641
V2642
V2649
V2651
V2652
V2681
V2682
V2689
V269
V270
V271
V272
V273
V274
V275
V276
V277
V279
V280
V281
V282
V283
V284
V285
V286
V2881
V2882
V2889
V289
V293
V299
V302
V312
V322
Suprv elderly primigrav
Suprv elderly multigrav
Suprv young primigravida
Suprv young multigravida
Pregnt-assist repro tech
Preg-hx in utro prev prg
Suprv high-risk preg NEC
Suprv high-risk preg NOS
Postpart care-lactation
Rout postpart follow-up
Prescrip-oral contracept
Initiate contracept NEC
Contracept mgmt-emergncy
Natrl fam pln-avoid preg
Contraceptive mangmt NEC
Insertion of iud
Contracept surveill NOS
Contracept pill surveill
Iud surveillance
Srvl mplnt sbdrm cntrcep
Contracept surveill NEC
Nsrt mplnt sbdrm cntrcep
Contraceptive mangmt NEC
Contraceptive mangmt NOS
Artificial insemination
Fertility testing
Sterilzation rev aftcare
Investigate & test NEC
Fem genetic test dis car
Female genetic test NEC
Genetic counseling
Male genetc test dis car
Test male part hab abort
Male genetic test NEC
Natrl family plan counsl
Fertlity preserv counsel
Procr mgmt cnsl/adv NEC
Tubal ligation status
Vasectomy status
Assist repro fertility
Fertility preserv proc
Procreative managemt NEC
Procreative mangmt NOS
Deliver-single liveborn
Deliver-single stillborn
Deliver-twins, both live
Del-twins, 1 nb, 1 sb
Deliver-twins, both sb
Del-mult birth, all live
Del-mult brth, some live
Del-mult birth, all sb
Outcome of delivery NOS
Screening-chromosom anom
Screen-alphafetoprotein
Screen by amniocent NEC
Scr fetl malfrm-ultrasnd
Screen-fetal retardation
Screen-isoimmunization
Antenatal screen strep b
Scrn fetal anatmc survey
Scrn risk preterm labor
Antenatal screening NEC
Antenatal screening NOS
NB obs genetc/metabl cnd
NB obsrv unsp suspct cnd
Single liveborn-nonhosp
Twin, mate lb-nonhosp
Twin, mate sb-nonhosp
Edit code lists 1.45
Unacceptable principal diagnoses
V332
V342
V352
V362
V372
V391
V392
V400
V401
V402
V403
V409
V410
V411
V412
V413
V414
V415
V416
V417
V418
V419
V420
V421
V422
V423
V424
V425
V426
V427
V4281
V4282
V4283
V4284
V4289
V429
V430
V431
V4321
V4322
V433
V434
V435
V4360
V4361
V4362
V4363
V4364
V4365
V4366
V4369
V437
V4381
V4382
V4383
V4389
V440
V441
V442
V443
V444
V4450
V4451
V4452
V4459
V446
V447
V448
Twin NOS-nonhosp
Oth multiple nb-nonhosp
Oth multiple sb-nonhosp
Multiple nb/sb-nonhosp
Mult birth NOS-nonhosp
Liveborn NOS-before adm
Liveborn NOS-nonhosp
Problems with learning
Prob with communication
Mental problems NEC
Behavioral problems NEC
Mental/behavior prob NOS
Problems with sight
Eye problems NEC
Problems with hearing
Ear problems NEC
Voice production problem
Smell and taste problem
Problem w swallowing
Sexual function problem
Probl w special func NEC
Probl w special func NOS
Kidney transplant status
Heart transplant status
Heart valve transplant
Skin transplant status
Bone transplant status
Cornea transplant status
Lung transplant status
Liver transplant status
Trnspl status-bne marrow
Trspl sts-perip stm cell
Trnspl status-pancreas
Trnspl status-intestines
Trnspl status organ NEC
Transplant status NOS
Eye replacement NEC
Lens replacement NEC
Heart assist dev replace
Artficial heart replace
Heart valve replac NEC
Blood vessel replac NEC
Bladder replacement NEC
Joint replaced unspcf
Joint replaced shoulder
Joint replaced elbow
Joint replaced wrist
Joint replaced hip
Joint replaced knee
Joint replaced ankle
Oth spcf joint replaced
Limb replacement NEC
Larynx replacement
Breast replacement
Artific skin repl status
Organ/tiss replacmnt NEC
Tracheostomy status
Gastrostomy status
Ileostomy status
Colostomy status
Enterostomy status NEC
Cystostomy status NOS
Cutaneous-vesicos status
Appendico-vesicos status
Cystostomy status NEC
Urinostomy status NEC
Artificial vagina status
Artif open status NEC
1.46 Definitions of Medicare Code Edits
V449
V4500
V4501
V4502
V4509
V4511
V4512
V452
V453
V454
V4551
V4552
V4559
V4561
V4569
V4572
V4573
V4574
V4575
V4576
V4577
V4578
V4579
V4581
V4582
V4583
V4584
V4585
V4586
V4587
V4588
V4589
V460
V462
V463
V468
V469
V470
V471
V472
V473
V474
V475
V479
V480
V481
V482
V483
V484
V485
V486
V487
V488
V489
V490
V491
V492
V493
V494
V495
V4960
V4961
V4962
V4963
V4964
V4965
V4966
V4967
Artif open status NOS
Status cardc dvce unspcf
Status cardiac pacemaker
Status autm crd dfbrltr
Status oth spcf crdc dvc
Renal dialysis status
Noncmplnt w renal dialys
Ventricular shunt status
Intestinal bypass status
Arthrodesis status
Prsc ntrutr cntrcptv dvc
Prsc sbdrml cntrcp mplnt
Prsc other cntrcptv dvc
Cataract extract status
Post-proc st eye/adn NEC
Acquire absnce intestine
Acquired absence kidney
Acq absence urinary trct
Acq absence of stomach
Acq absence of lung
Acq absnce genital organ
Acquired absence of eye
Acq absence of organ NEC
Aortocoronary bypass
Status-post ptca
Breast impl remov status
Dental restoratn status
Insulin pump status
Bariatric surgery status
Trnsplnt orgn rem status
TPA adm status 24 hr pta
Post-proc states NEC
Dependence on aspirator
Depend-supplement oxygen
Wheelchair dependence
Machine dependence NEC
Machine dependence NOS
Intern organ deficiency
Mech prob w internal org
Cardiorespirat probl NEC
Digestive problems NEC
Urinary problems NEC
Genital problems NEC
Probl w internal org NOS
Deficiencies of head
Deficiencies neck/trunk
Mechanical prob w head
Mech prob w neck & trunk
Sensory problem w head
Sensor prob w neck/trunk
Disfigurements of head
Disfigurement neck/trunk
Prob-head/neck/trunk NEC
Prob-head/neck/trunk NOS
Deficiencies of limbs
Mechanical prob w limbs
Motor problems w limbs
Sensory problems w limbs
Disfigurements of limbs
Limb problems NEC
Status amput up lmb NOS
Status amput thumb
Status amput oth fingers
Status amput hand
Status amput wrist
Status amput below elbow
Status amput above elbow
Status amput shoulder
October 2009
Unacceptable principal diagnoses
V4970
V4971
V4972
V4973
V4974
V4975
V4976
V4977
V4981
V4982
V4983
V4984
V4985
V4989
V499
V503
V508
V509
V529
V531
V532
V534
V5350
V5351
V5359
V536
V537
V538
V5390
V5391
V5399
V549
V559
V562
V5631
V5632
V570
*V571
*V5721
*V5722
*V573
V574
V5781
*V5789
*V579
V582
V5830
V5831
V5832
V5862
V5863
V5864
V5865
V589
V5901
V5902
V5909
V5970
V5971
V5972
V5973
V5974
V600
V601
V602
V603
V604
V605
Status amput lwr lmb NOS
Status amput great toe
Status amput othr toe(s)
Status amput foot
Status amput ankle
Status amput below knee
Status amput above knee
Status amput hip
Asympt postmeno status
Dental sealant status
Await organ transplnt st
Bed confinement status
Dual sensory impairment
Conditn influ health NEC
Probl influ health NOS
Ear piercing
Elective surgery NEC
Elective surgery NOS
Fitting prosthesis NOS
Fit contact lens/glasses
Adjustment hearing aid
Fit orthodontic device
Fit/adjust intestinl dev
Fit/adj gastric lap band
Fit/adjust gi app-device
Fitting urinary devices
Fit orthopedic devices
Adjustment of wheelchair
Fit/adjust device NOS
Fit/adjust insulin pump
Fit/adjust device NEC
Orthopedic aftercare NOS
Attn to artif open NOS
Fit/adj perit dial cath
Hemodialysis testing
Peritoneal dialysis test
Breathing exercises
Physical therapy NEC
Encntr occupatnal thrpy
Encntr vocational thrpy
Speech-language therapy
Orthoptic training
Orthotic training
Rehabilitation proc NEC
Rehabilitation proc NOS
Blood transfusion, no dx
Attn rem nonsurg dressng
Attn rem surg dressing
Attn removal of sutures
Long-term use antibiotic
Lng use antiplte/thrmbtc
Long-term anti-inflamtry
Long-term use steroids
Aftercare NOS
Blood donor-whole blood
Blood donor-stem cells
Blood donor NEC
Egg donor NEC
Egg donor age <35 anon
Egg donor age <35 desig
Egg donor age 35+ anon
Egg donor age 35+ desig
Lack of housing
Inadequate housing
Economic problem
Person living alone
No family able to care
Holiday relief care
October 2009
V606
V6081
V6089
V609
V6101
V6102
V6103
V6104
V6105
V6106
V6107
V6108
V6109
V6110
V6111
V6112
V6120
V6122
V6123
V6124
V6125
V6129
V613
V6141
V6142
V6149
V615
V616
V617
V618
V619
V620
V621
V6221
V6222
V6229
V623
V624
V625
V626
V6281
V6282
V6283
V6289
V629
V630
V631
V632
V638
V639
V6400
V6401
V6402
V6403
V6404
V6405
V6406
V6407
V6408
V6409
V641
V642
V643
V6441
V6442
V6443
V6511
V6519
Person in resident inst
Foster care (status)
Housing/econo circum NEC
Housing/econo circum NOS
Fmily dsrpt-fam military
Fmily dsrpt-ret military
Fmily dsrpt- divorce/sep
Family dsrpt-estrangmemt
Famly dsrpt-chld custody
Family dsrpt-foster care
Family dsrpt-death membr
Fmly dsrp-fam absnce NEC
Family disruption NEC
Consl partner prob
Cnsl victm partner abuse
Cnsl perp partner abuse
Cnsl prnt-chld prob NOS
Cnsl perp parent chld ab
Cnsl prnt-biol chld prob
Cnsl prnt-adpt chld prob
Cnsl prnt-fstr chld prob
Oth parent-child problem
Problem w aged parent
Alcoholism in family
Substance abuse-family
Family health probl NEC
Multiparity
Illegitimate pregnancy
Unwanted pregnancy NEC
Family circumstances NEC
Family circumstance NOS
Unemployment
Adverse eff-work environ
Hx military deployment
Hx retrn military deploy
Occupationl circumst NEC
Educational circumstance
Social maladjustment
Legal circumstances
Refusal of treatment
Interpersonal probl NEC
Bereavement, uncomplicat
Cnsl perp phys/sex abuse
Psychological stress NEC
Psychosocial circum NOS
Home remote from hospitl
No medical serv in home
Wait adm to oth facility
No med facilities NEC
No med facilities NOS
No vaccination NOS
No vaccin-acute illness
No vaccin-chronc illness
No vaccin-immune comp
No vaccin-allergy to vac
No vaccin-caregiv refuse
No vaccination-pt refuse
No vaccination-religion
No vaccin-prev disease
No vaccination NEC
No proc/contraindication
No proc/patient decision
No proc for reasons NEC
Lap surg convert to open
Thoracoscop conv to open
Arthroscopc conv to open
Ped pre-brth vst-parent
Person consult for anoth
Edit code lists 1.47
Unacceptable principal diagnoses
V653
V6540
V6541
V6542
V6543
V6544
V6545
V6546
V6549
V655
V658
V659
V665
V667
V669
V679
V6801
V6809
V681
V682
V6881
V6889
V689
V690
V691
V692
V693
V695
V698
V699
V700
V702
V703
V706
V708
V709
V719
V7211
V7212
V7219
V722
V725
V7260
V7261
V7262
V7263
V7269
V727
V7284
V7285
V7286
V729
V730
V731
V732
V733
V734
V735
V736
V7381
V7388
V7389
V7398
V7399
V740
V741
V742
V743
Dietary surveil/counsel
Counseling NOS
Exercise counseling
Counslng sbstn use abuse
Counseling injry prevent
Hiv counseling
Consln ot sex trnsmt dis
Insulin pump training
Other specfd counseling
Persn w feared complaint
Reason for consult NEC
Reason for consult NOS
Convalescence NEC
Encountr palliative care
Convalescence NOS
Follow-up exam NOS
Disability examination
Issue of med certif NEC
Issue repeat prescript
Request expert evidence
Referral-no exam/treat
Administrtve encount NEC
Administrtve encount NOS
Lack of physical exercse
Inapprt diet eat habits
High-risk sexual behavr
Gambling and betting
Behav insomnia-childhood
Oth prblms rltd lfstyle
Prblm rltd lfstyle NOS
Routine medical exam
Gen psychiatric exam NEC
Med exam NEC-admin purp
Health exam-pop survey
General medical exam NEC
General medical exam NOS
Observ-suspect cond NOS
Hearing exam-fail screen
Hearing conservatn/trtmt
Exam ears & hearing NEC
Dental examination
Radiological exam NEC
Laboratory exam NOS
Antibody response exam
Routine physicl lab exam
Pre-procedure lab exam
Laboratory exam NEC
Skin/sensitization tests
Preop exam unspcf
Oth specified exam
Blood typing encounter
Examination NOS
Screening-poliomyelitis
Screening for smallpox
Screening for measles
Screening for rubella
Screening-yellow fever
Screening-arbovirus dis
Screening for trachoma
Special screen exam HPV
Scrn oth spcf chlmyd dis
Scrn oth spcf viral dis
Scrn unspcf chlmyd dis
Scrn unspcf viral dis
Screening for cholera
Screening-pulmonary TB
Screening for leprosy
Screening for diphtheria
1.48 Definitions of Medicare Code Edits
V744
V745
V746
V748
V749
V750
V751
V752
V753
V754
V755
V756
V757
V758
V759
V760
V7610
V7611
V7612
V7619
V762
V763
V7641
V7642
V7643
V7645
V7646
V7647
V7649
V7650
V7651
V7652
V7681
V7689
V769
V770
V771
V772
V773
V774
V775
V776
V777
V778
V7791
V7799
V780
V781
V782
V783
V788
V789
V790
V791
V792
V793
V798
V799
V8001
V8009
V801
V802
V803
V810
V811
V812
V813
V814
Screen-bact conjunctivit
Screen for veneral dis
Screening for yaws
Screen-bacterial dis NEC
Screen-bacterial dis NOS
Screen-rickettsial dis
Screening for malaria
Screen for leishmaniasis
Screen-trypanosomiasis
Screen-mycotic infect
Screen-schistosomiasis
Screen for filariasis
Screen for helminthiasis
Screen-parasitic dis NEC
Screen for infec dis NOS
Screen mal neop-resp org
Scrn mal neo breast NOS
Screen mammogram hi risk
Screen mammogram NEC
Scrn mal neo breast NEC
Screen mal neop-cervix
Screen mal neop-bladder
Screen mal neop-rectum
Screen mal neop-oral cav
Screen mal neop-skin
Screen malig neop-testis
Screen malig neop-ovary
Screen malig neop-vagina
Screen mal neop oth site
Scrn malig neo-intes NOS
Screen malig neop-colon
Scrn mal neo-small intes
Screen neop-nervous syst
Screen neoplasm NEC
Screen-neoplasm NOS
Screen-thyroid disorder
Screen-diabetes mellitus
Screen for malnutrition
Screen-phenylketonuria
Screen for galactosemia
Screening for gout
Screen-cystic fibrosis
Screen-inborn err metab
Screening for obesity
Screen lipoid disorders
Screen-endoc/nut/met NEC
Screen-iron defic anemia
Screen-defic anemia NEC
Screen-sickle cell dis
Scrn-hemoglobinopath NEC
Screen-blood dis NEC
Screen-blood dis NOS
Screening for depression
Screening for alcoholism
Screen-mental retardat
Screen-development prob
Screen-mental dis NEC
Screen-mental dis NOS
Screen-traumtc brain inj
Screen-neuro condition
Screening for glaucoma
Screening-eye cond NEC
Screening for ear dis
Scrn-ischemic heart dis
Screen for hypertension
Screen-cardiovasc NEC
Screen-bronch/emphysema
Screen-respir cond NEC
October 2009
Unacceptable principal diagnoses
V815
V816
V820
V821
V822
V823
V824
V825
V826
V8271
V8279
V8281
V8289
V829
V8301
V8302
V8381
V8389
V8401
V8402
V8403
V8404
V8409
V8481
V8489
V850
V851
V8521
V8522
V8523
V8524
V8525
V8530
V8531
V8532
V8533
V8534
V8535
Screen for nephropathy
Screen for gu cond NEC
Screen for skin cond
Screen-rheumatoid arthr
Screen-rheumat dis NEC
Screen-cong hip dislocat
Mat pstntl scr-chrm anom
Screen-contamination NEC
Multiphasic screening
Screen-gentc dis carrier
Genetic screening NEC
Screen - osteoporosis
Screen for condition NEC
Screen for condition NOS
Asympt hemoph a carrier
Sympt hemophil a carrier
Cystic fibrosis gene car
Genetic carrier stat NEC
Genetc sus mal neo brest
Genetc sus mal neo ovary
Genetc sus mal neo prost
Genetc susc mal neo endo
Genetic susc mal neo NEC
Genetc sus mult endo neo
Genetic suscept dis NEC
BMI less than 19,adult
BMI between 19-24,adult
BMI 25.0-25.9,adult
BMI 26.0-26.9,adult
BMI 27.0-27.9,adult
BMI 28.0-28.9,adult
BMI 29.0-29.9,adult
BMI 30.0-30.9,adult
BMI 31.0-31.9,adult
BMI 32.0-32.9,adult
BMI 33.0-33.9,adult
BMI 34.0-34.9,adult
BMI 35.0-35.9,adult
October 2009
V8536
V8537
V8538
V8539
V854
V8551
V8552
V8553
V8554
V860
V861
V8701
V8709
V8711
V8712
V8719
V872
V8731
V8732
V8739
V8741
V8742
V8743
V8744
V8745
V8746
V8749
V8801
V8802
V8803
V8901
V8902
V8903
V8904
V8905
V8909
BMI 36.0-36.9,adult
BMI 37.0-37.9,adult
BMI 38.0-38.9,adult
BMI 39.0-39.9,adult
BMI 40 and over,adult
BMI,pediatric <5%
BMI,pediatric 5% - <85%
BMI,pediatric 85% - <95%
BMI,pediatric >= 95%
Estrogen recep pstv stat
Estrogen recep neg stat
Contact/exposure arsenic
Cntct/exp hazrd metl NEC
Cntct/exp aromatc amines
Contact/exposure benzene
Cont/exp haz aromat NEC
Cont/exp hazard chem NEC
Contact/exposure mold
Contact/exp algae bloom
Cont/exp hazard sub NEC
Hx antineoplastic chemo
Hx monoclonal drug thrpy
Hx estrogen therapy
Hx inhaled steroid thrpy
Hx systemc steroid thrpy
Hx immunosuppres thrpy
Hx drug therapy NEC
Acq absnce cervix/uterus
Acq ab ut remn cerv stmp
Acq absnc cerv/remain ut
Sus amntc cav/mem nt fnd
Sus placentl prob nt fnd
Sus fetal anomaly nt fnd
Sus fetal growth not fnd
Sus cervcl shortn nt fnd
Oth sus mat/ftl nt fnd
Edit code lists 1.49
10.10.
Non-specific
O.R. procedure
Non-specific
O.R.
procedure
11. Non-covered procedure
Effective 10/01/07, the non-specific O.R. procedure edit was
discontinued and will appear for claims processed using MCE version 2.0-23.0 only.
There are some procedures for which Medicare does not provide
reimbursement. There are also procedures that would normally not be
reimbursed by Medicare but due to the presence of certain diagnoses
are reimbursed.
The following page contains lists of non-covered procedure codes
with corresponding English descriptions, and explains the circumstances in which the edit is applied.
1.50 Definitions of Medicare Code Edits
October 2009
Non-covered procedures
1. The following criteria are retroactive effective November 6, 2006.
The procedure shown below is identified as a non-covered procedure except when combined with
non-operating room procedure code 0065 (Perc ins intracran stent).
Procedure
0062
Perc angio intracran ves
2. The following criteria are retroactive effective April 26, 2006.
ICD-9-CM procedure codes 5280 (Pancreat transplant NOS) and 5282 (Pancreatic homotransplan) alone
[without 5569 (Kidney transplant NEC)] are considered “Non-covered procedures” except for the following condition:
When either 5280 or 5282 is combined with at least one principal or secondary diagnosis code from the
following diagnoses list:
Diagnoses list
25001
25003
25011
25013
25021
25023
25031
25033
25041
25043
25051
25053
25061
25063
25071
25073
25081
25083
25091
25093
DMI wo cmp nt st uncntrl
DMI wo cmp uncntrld
DMI keto nt st uncntrld
DMI ketoacd uncontrold
DMI hprsm nt st uncntrld
DMI hprosmlr uncontrold
DMI o cm nt st uncntrld
DMI oth coma uncontrold
DMI renl nt st uncntrld
DMI renal uncntrld
DMI ophth nt st uncntrld
DMI ophth uncntrld
DMI neuro nt st uncntrld
DMI neuro uncntrld
DMI circ nt st uncntrld
DMI circ uncntrld
DMI oth nt st uncntrld
DMI oth uncntrld
DMI unspf nt st uncntrld
DMI unspf uncntrld
3. The following criteria are retroactive effective May 1, 2008.
The procedure shown below is identified as a non-covered procedure except when combined with
diagnosis code V707 (Examination of participant in clinical trial).
Procedure
3752
Implantation of total internal biventricular heart replacement system
October 2009
Edit code lists 1.51
Non-covered procedures
The procedures shown below are always identified as non-covered procedures.
1171
1172
1175
1176
3735
3753
3754
3928
4493
5051
5283
5796
5797
6370
Keratomileusis
Keratophakia
Radial keratotomy
Epikeratophakia
Partial ventriculectomy
Repl/rep thr unt tot hrt
Repl/rep oth tot hrt sys
Extracran-intracr bypass
Insert gastric bubble
Auxiliary liver transpl
Pancreatic heterotranspl
Implant bladder stimulat
Replace bladder stimulat
Male sterilization NOS
6371
6372
6373
645
6621
6622
6629
6631
6632
6639
9852
9859
Ligation of vas deferens
Spermatic cord ligation
Vasectomy
Sex transformat op NEC
Bilat endosc crush tube
Bilat endosc divis tube
Bilat endos occ tube NEC
Bilat tubal crushing NEC
Bilat tubal division NEC
Bilat tubal destruct NEC
Eswl gb/bile duct
Eswl other sites
The procedures shown below are identified as non-covered procedures only when any of the diagnoses in the right hand list are present as either a principal or secondary diagnosis.
Procedures
Diagnoses
4101
4104
4107
4109
20400
20500
20510
20511
20600
20700
20800
Auto bone mt w/o purg
Auto hem stem ct w/o pur
Auto hem stem ct w purg
Auto bone mt w purging
Ac lym leuk wo achv rmsn
Ac myl leuk wo achv rmsn
Ch myl leuk wo achv rmsn
Chr myl leuk w rmsion
Ac mono leu wo achv rmsn
Ac erth/erlk wo ach rmsn
Ac leu un cl wo ach rmsn
The procedures shown below are identified as non-covered procedures only when any of the diagnoses in the right hand list are present as either a principal or secondary diagnosis.
Procedures
Diagnoses
4102
4103
4105
4108
20300
20301
Alo bone marrow trnsplnt
Allogrft bone marrow NOS
Allo hem stem ct w/o pur
Allo hem stem ct w purg
Mult mye w/o achv rmson
Mult myelm w remission
The procedure shown below is identified as a “Non-covered procedure” when the
benefciary is over age 60.
Procedure
8465
Ins totl disc pros lumb
1.52 Definitions of Medicare Code Edits
October 2009
12. Open biopsy check
Biopsies can be performed as open biopsies, percutaneously, or endoscopically. The DRG Definitions assign a patient to different DRGs
depending on whether or not the biopsy was open. In general, for
most organ systems, open biopsies are performed infrequently. There
are explicit ICD-9-CM codes for open and non-open biopsies. Since
the distinction made between the different biopsy codes is not applied
uniformly, the Medicare Code Editor identifies all biopsies that are
coded as open biopsies.
The following list contains codes, with corresponding English
descriptions, that are flagged for an open biopsy check.
Open biopsy procedures
Non-open biopsy procedures
0112
0114
0412
0612
0712
2212
2502
2612
3145
Open cereb meninges bx
Open brain biopsy
Open periph nerve biopsy
Open thyroid gland bx
Open adrenal gland bx
Open biopsy nasal sinus
Open biopsy of tongue
Open bx saliv gland/duct
Opn bx larynx or trachea
0111
0113
0411
0611
0711
2211
2501
2611
3143
3325
3328
3426
4133
4225
4415
4515
4526
4825
5012
5113
5212
5423
5524
5634
5734
6012
6014
6212
6813
6814
8512
Open bronchial biopsy
Open lung biopsy
Open mediastinal biopsy
Open spleen biopsy
Open biopsy of esophagus
Open gastric biopsy
Open small bowel biopsy
Open large bowel biopsy
Open rectal biopsy
Open liver biopsy
Open biliary tract bx
Open pancreatic biopsy
Peritoneal biopsy
Open renal biopsy
Open ureteral biopsy
Open bladder biopsy
Open prostatic biopsy
Open seminal vesicles bx
Open testicular biopsy
Open uterine biopsy
Open uterine ligament bx
Open breast biopsy
3144
3324
3326
3425
4132
4224
4414
4514
4525
4824
5011
5112
5211
5424
5523
5632
5733
6011
6013
6211
6816
6815
8511
October 2009
Clos cereb meninges bx
Closed brain biopsy
Clos periph nerve biopsy
Closed thyroid gland bx
Closed adrenal gland bx
Closed nasal sinus bx
Closed biopsy of tongue
Clos bx saliv gland/duct
Closed biopsy larynx
or
Closed biopsy trachea
Closed bronchial biopsy
Closed lung biopsy
Clos mediastinal biopsy
Closed spleen biopsy
Closed bx of esophagus
Closed gastric biopsy
Clos small bowel biopsy
Clos large bowel biopsy
Closed rectal biopsy
Closed liver biopsy
Percu bx gb/bile duct
Closed pancreatic biopsy
Closed intra-abd mass bx
Closed renal biopsy
Closed ureteral biopsy
Clos transureth bladd bx
Closed prostatic biopsy
Clos seminal vesicles bx
Closed testicular biopsy
Closed uterine biopsy
Clos uterine ligament bx
Closed breast biopsy
Edit code lists 1.53
13. Bilateral procedure
Certain codes do not accurately reflect procedures performed in one
admission on two or more different bilateral joints of the lower
extremities. A combination of these codes shows a bilateral procedure when they could be procedures performed on a single joint (i.e.,
duplicate procedures). For example, if 8151 (Total hip replacement)
and 8152 (Partial hip replacement) are both coded on the claim, the
edit “bilateral procedure” will appear.
This edit instructs the fiscal intermediary to ensure that these procedures were performed on two separate joints. However, if 8151 (Total
hip replacement) is coded twice, the edit would not appear because
this signifies a true bilateral procedure.
The following list contains the joint replacement procedure codes
with corresponding English descriptions identified as “bilateral procedure” whenever two or more different joint procedures are coded,
and the principal diagnosis causes assignment to MDC 8.
Bilateral procedure codes
0070
0080
0085
0086
0087
8151
8152
8154
8156
1.54 Definitions of Medicare Code Edits
Rev hip repl-acetab/fem
Rev knee replacemt-total
Resrf hip,total-acet/fem
Resrf hip,part-fem head
Resrf hip,part-acetablum
Total hip replacement
Partial hip replacement
Total knee replacement
Total ankle replacement
October 2009
14. Invalid age
A patient’s age may be necessary for appropriate DRG determination.
If the age reported is not between 0 years and 124 years, the Medicare Code Editor will assume the age is in error.
15. Invalid sex
A patient’s sex (gender) may be necessary for appropriate DRG determination. The sex code reported must be either 1 (male) or 2 (female).
16. Invalid discharge status
A patient’s discharge status may be necessary for appropriate DRG
determination. Discharge status must be coded according to the
UB-04 conventions. Valid values are:
01 = Home or self-care
02 = Disch/trans to another short term hospital
03 = Disch/trans to SNF
04 = Disch/trans to ICF
05 = Disch/trans to another type of facility (valid until 03/31/08)
05 = Disch/trans to a designated cancer center or children’s hospital (added
04/01/08)
06 = Care of home health service
07 = Left against medical advice
08 = Home IV service (deleted 10/01/05)
20 = Died
21 = Court/law enfrc (added 10/1/09)
30 = Still a patient
43 = Fed hospital (added 10/01/03)
50 = Hospice-home
51 = Hospice-medical facility
61 = Swing Bed (added 10/01/2001)
62 = Rehab facility/rehab unit (added 10/01/2001)
63 = Long term care hospital (added 10/01/2001)
64 = Nursing facility–Medicaid certified (added 10/01/02)
65 = Psych hosp/unit (added 10/01/03)
66 = Critical access hospital (added 10/01/05)
70 = Discharge/transfer to another type of health care institution not defined
elsewhere in the code list (added 04/01/08)
71 = Outpatient services-other facility (10/01/01–09/30/03 only)
72 = Outpatient services-this facility (10/01/01–09/30/03 only)
October 2009
Edit code lists 1.55
17. Limited coverage
For certain procedures whose medical complexity and serious nature
incur extraordinary associated costs, Medicare limits coverage to a
portion of the cost.
The limited coverage edit indicates the type of limited coverage. (e.g.,
Heart transplant-Limited coverage, Lung transplant-Limited coverage,
etc.)
The following is a list of limited coverage procedure codes with corresponding English descriptions.
Limited coverage
3222
3350
3351
3352
336
3751
3766
4697
5059
5280
5282
5569
Lung vol reduction surg
Lung transplant NOS
Unilat lung transplant
Bilat lung transplant
Comb heart/lung transpla
Heart transplantation
Implantable hrt assist
Transplant of intestine
Liver transplant NEC
Pancreas transplant NOS
Pancreatic homotransplan
Kidney tansplant NEC
The following criteria are retroactive effective May 1, 2008.
The procedure shown below is identified as a limited
coverage procedure when combined with diagnosis code V707
(Examination of participant in clinical trial).
Procedure
3752
1.56 Definitions of Medicare Code Edits
Imp tot int bi ht rp sys
October 2009
Wrong procedure performed
18. Wrong
procedure
18. Wrong
procedure
performed
performed
Certain E-codes indicate that the wrong procedure was
performed.
The following list contains the codes, with corresponding English
descriptions, that indicate the wrong procedure was performed.
Wrong procedure performed
E8765
E8766
E8767
Perfrm wrong op/right pt
Proc-pt not sched surg
Rt proc-wrong side/part
October 2009
Edit code lists 1.57
1.58 Definitions of Medicare Code Edits
October 2009
Preliminary
06/12/09
Chapter 2
Code list changes
2
06/12/09
Contents
Code list changes
2.3
Changes to existing edits
New edit 2.13
2.2 Definitions of Medicare Code Edits
Preliminary
2.3
October 2009
Preliminary
06/12/09
Chapter 2
Code list changes
T
HIS CHAPTER SUMMARIZES the changes in the edit code lists
from the last release of the Medicare Code Editor (MCE) software to
the current one. The code lists are part of chapter 1 in this manual.
Changes to existing edits
Diagnoses for Newborns
The following codes were added:
768.70 Hypoxic-ischemic encephalopathy, unspecified
768.71 Mild hypoxic-ischemic encephalopathy
768.72 Moderate hypoxic-ischemic encephalopathy
768.73 Severe hypoxic-ischemic encephalopathy
779.31 Feeding problems in newborn
779.32 Bilious vomiting in newborn
779.33 Other vomiting in newborn
779.34 Failure to thrive in newborn
V20.31 Health supervision for newborn under 8 days
V20.32 Health supervision for newborn 8 to 28 days old
The following codes were removed:
768.7 Hypoxic-ischemic encephalopathy (HIE)
779.3 Feeding problems in newborn
October 2009
Code list changes 2.3
06/12/09
Preliminary
Diagnoses for Pediatrics - (age 0-17)
The following codes were added:
789.7 Colic
799.82 Apparent life threatening event in infant
Diagnoses for Maternity -age 12-55 years old
The following codes were added:
670.10 Puerperal endometritis, unspecified as to episode of care
or not applicable
670.12 Puerperal endometritis, delivered, with mention of postpartum complication
670.14 Puerperal endometritis, postpartum condition or
complication
670.20 Puerperal sepsis, unspecified as to episode of care or not
applicable
670.22 Puerperal sepsis, delivered, with mention of postpartum
complication
670.24 Puerperal sepsis, postpartum condition or complication
670.30 Puerperal septic thrombophlebitis, unspecified as to episode of care or not applicable
670.32 Puerperal septic thrombophlebitis, delivered, with mention of postpartum complication
670.34 Puerperal septic thrombophlebitis, postpartum condition
or complication
670.80 Other major puerperal infection, unspecified as to episode of care or not applicable
670.82 Other major puerperal infection, delivered, with mention
of postpartum complication
670.84 Other major puerperal infection, postpartum condition or
complication
The following code was removed:
V65.11 Pediatric pre-birth visit for expectant parent(s)
Diagnoses for Females Only
The following codes were added:
621.34 Benign endometrial hyperplasia
621.35 Endometrial intraepithelial neoplasia [EIN]
670.10 Puerperal endometritis, unspecified as to episode of care
or not applicable
670.12 Puerperal endometritis, delivered, with mention of postpartum complication
670.20 Puerperal sepsis, unspecified as to episode of care or not
applicable
2.4 Definitions of Medicare Code Edits
October 2009
Preliminary
06/12/09
670.22 Puerperal sepsis, delivered, with mention of
postpartum complication
670.24 Puerperal sepsis, postpartum condition or complication
670.30 Puerperal septic thrombophlebitis, unspecified as to episode of care or not applicable
670.32 Puerperal septic thrombophlebitis, delivered, with mention of postpartum complication
670.34 Puerperal septic thrombophlebitis, postpartum condition
or complication
670.80 Other major puerperal infection, unspecified as to episode of care or not applicable
670.82 Other major puerperal infection, delivered, with mention
of postpartum complication
670.84 Other major puerperal infection, postpartum condition or
complication
The following code was removed:
V65.11 Pediatric pre-birth visit for expectant parent(s)
Diagnoses for Males Only
The following codes were added:
603.0 Encysted hydrocele
603.1 Infected hydrocele
603.8 Other hydrocele
603.9 Hydrocele NOS
Procedures Allowed for Females Only
The following codes were added:
75.37 Amnioinfusion
75.38 Fetal pulse oximetry
Manifestations Not Allowed as Principal Diagnoses
The following codes were removed:
365.41 Glaucoma associated with chamber angle anomalies
365.42 Glaucoma associated with anomalies of iris
365.43 Glaucoma associated with other anterior segment
anomalies
October 2009
Code list changes 2.5
06/12/09
Preliminary
Unacceptable Principal Diagnoses
The following codes were added:
V10.90 Personal history of unspecified type of malignant
neoplasm
V10.91 Personal history of malignant neuroendocrine tumor
V15.52 Personal history of traumatic brain injury
V15.80 Personal history of failed moderate sedation
V15.83 Personal history of underimmunization status
V20.31 Health supervision for newborn under 8 days
V20.32 Health supervision for newborn 8 to 28 days old
V26.42 Encounter for fertility preservation counseling
V26.82 Encounter for fertility preservation procedure
V53.50 Fitting and adjustment of intestinal appliance and device
V53.51 Fitting and adjustment of gastric lap band
V53.59 Fitting and adjustment of other gastrointestinal
appliance and device
V60.81 Foster care (status)
V60.89 Other specified housing or economic circumstances
V61.07 Family disruption due to death of family member
V61.08 Family disruption due to other extended absence of family member
V61.23 Counseling for parent-biological child problem
V61.24 Counseling for parent-adopted child problem
V61.25 Counseling for parent (guardian)-foster child problem
V61.42 Substance abuse in family
V72.60 Laboratory examination, unspecified
V72.61 Antibody response examination
V72.62 Laboratory examination ordered as part of a routine general medical examination
V72.63 Pre-procedural laboratory examination
V72.69 Other laboratory examination
V80.01 Special screening for traumatic brain injury
V80.09 Special screening for other neurological conditions
V87.32 Contact with and (suspected) exposure to algae bloom
V87.43 Personal history of estrogen therapy
V87.44 Personal history of inhaled steroid therapy
V87.45 Personal history of systemic steroid therapy
V87.46 Personal history of immunosuppressive therapy
The following codes were removed:
209.00 Malignant carcinoid tumor of the small intestine, unspecified portion
209.01 Malignant carcinoid tumor of the duodenum
209.02 Malignant carcinoid tumor of the jejunum
209.03 Malignant carcinoid tumor of the ileum
209.10 Malignant carcinoid tumor of the large intestine, unspecified portion
2.6 Definitions of Medicare Code Edits
October 2009
Preliminary
06/12/09
209.11
209.12
209.13
209.14
209.15
209.16
209.17
209.20
209.21
209.22
209.23
209.24
209.25
209.26
209.27
209.29
209.30
209.40
209.41
209.42
209.43
209.50
209.51
209.52
209.53
209.54
209.55
209.56
209.57
209.60
209.61
209.62
209.63
209.64
209.65
209.66
209.67
209.69
October 2009
Malignant carcinoid tumor of the appendix
Malignant carcinoid tumor of the cecum
Malignant carcinoid tumor of the ascending colon
Malignant carcinoid tumor of the transverse colon
Malignant carcinoid tumor of the descending colon
Malignant carcinoid tumor of the sigmoid colon
Malignant carcinoid tumor of the rectum
Malignant carcinoid tumor of unknown primary site
Malignant carcinoid tumor of the bronchus and lung
Malignant carcinoid tumor of the thymus
Malignant carcinoid tumor of the stomach
Malignant carcinoid tumor of the kidney
Malignant carcinoid tumor of foregut, not otherwise
specified
Malignant carcinoid tumor of midgut, not otherwise
specified
Malignant carcinoid tumor of hindgut, not otherwise
specified
Malignant carcinoid tumor of other sites
Malignant poorly differentiated neuroendocrine carcinoma, any site
Benign carcinoid tumor of the small intestine, unspecified portion
Benign carcinoid tumor of the duodenum
Benign carcinoid tumor of the jejunum
Benign carcinoid tumor of the ileum
Benign carcinoid tumor of the large intestine, unspecified
portion
Benign carcinoid tumor of the appendix
Benign carcinoid tumor of the cecum
Benign carcinoid tumor of the ascending colon
Benign carcinoid tumor of the transverse colon
Benign carcinoid tumor of the descending colon
Benign carcinoid tumor of the sigmoid colon
Benign carcinoid tumor of the rectum
Benign carcinoid tumor of unknown primary site
Benign carcinoid tumor of the bronchus and lung
Benign carcinoid tumor of the thymus
Benign carcinoid tumor of the stomach
Benign carcinoid tumor of the kidney
Benign carcinoid tumor of foregut, not otherwise
specified
Benign carcinoid tumor of midgut, not otherwise
specified
Benign carcinoid tumor of hindgut, not otherwise
specified
Benign carcinoid tumor of other sites
Code list changes 2.7
06/12/09
V10.9
V53.5
V60.8
V72.6
V80.0
Preliminary
Unspecified personal history of malignant neoplasm
Fitting and adjustment of other intestinal appliance
Other specified housing or economic circumstances
Laboratory examination
Special screening for neurological conditions
E-Code as PDX
The following codes were added:
E000.0 Civilian activity done for income or pay
E000.1 Military activity
E000.8 Other external cause status
E000.9 Unspecified external cause status
E001.0 Activities involving walking, marching and hiking
E001.1 Activities involving running
E002.0 Activities involving swimming
E002.1 Activities involving springboard and platform diving
E002.2 Activities involving water polo
E002.3 Activities involving water aerobics and water exercise
E002.4 Activities involving underwater diving and snorkeling
E002.5 Activities involving rowing, canoeing, kayaking, rafting
and tubing
E002.6 Activities involving water skiing and wake boarding
E002.7 Activities involving surfing, windsurfing and boogie
boarding
E002.8 Activities involving water sliding
E002.9 Other activity involving water and watercraft
E003.0 Activities involving ice skating
E003.1 Activities involving ice hockey
E003.2 Activities involving snow (alpine) (downhill) skiing,
snow boarding, sledding, tobogganing and snow tubing
E003.3 Activities involving cross country skiing
E003.9 Other activity involving ice and snow
E004.0 Activities involving mountain climbing, rock climbing
and wall climbing
E004.1 Activities involving rappelling
E004.2 Activities involving climbing BASE jumping
E004.3 Activities involving climbing bungee jumping
E004.4 Activities involving hang gliding
E004.9 Other activity involving climbing, rappelling and jumping off
E005.0 Activities involving dancing
E005.1 Activities involving yoga
E005.2 Activities involving gymnastics
E005.3 Activities involving trampoline
E005.4 Activities involving cheerleading
2.8 Definitions of Medicare Code Edits
October 2009
Preliminary
06/12/09
E005.9 Other activity involving dancing and other rhythmic
movements
E006.0 Activities involving roller skating (inline) and
skateboarding
E006.1 Activities involving horseback riding
E006.2 Activities involving golf
E006.3 Activities involving bowling
E006.4 Activities involving bike riding
E006.5 Activities involving jump rope
E006.6 Activities involving non-running track and field events
E006.9 Other activity involving other sports and athletics played
individually
E007.0 Activities involving american tackle football
E007.1 Activities involving american flag or touch football
E007.2 Activities involving rugby
E007.3 Activities involving baseball
E007.4 Activities involving lacrosse and field hockey
E007.5 Activities involving soccer
E007.6 Activities involving basketball
E007.7 Activities involving volleyball (beach) (court)
E007.8 Activities involving physical games generally associated
with school recess, summer camp and children
E007.9 Other activity involving other sports and athletes played
as a team or group
E008.0 Activities involving boxing
E008.1 Activities involving wrestling
E008.2 Activities involving racquet and hand sports
E008.3 Activities involving frisbee
E008.4 Activities involving martial arts
E008.9 Other specified sports and athletics activities
E009.0 Activity involving exercise machines primarily for cardiorespiratory conditioning
E009.1 Activity involving calisthenics
E009.2 Activity involving aerobic and step exercise
E009.3 Activity involving circuit training
E009.4 Activity involving obstacle course
E009.5 Activity involving grass drills
E009.9 Other activity involving cardiorespiratory exercise
E010.0 Activity involving exercise machines primarily for muscle strengthening
E010.1 Activity involving push-ups, pull-ups, sit-ups
E010.2 Activity involving free weights
E010.3 Activity involving pilates
E010.9 Other activity involving other muscle strengthening
exercises
E011.0 Activities involving computer keyboarding
October 2009
Code list changes 2.9
06/12/09
Preliminary
E011.1 Activities involving hand held interactive electronic
device
E011.9 Other activity involving computer technology and electronic devices
E012.0 Activities involving knitting and crocheting
E012.1 Activities involving sewing
E012.2 Activities involving furniture building and finishing
E012.9 Activity involving other arts and handcrafts
E013.0 Activities involving personal bathing and showering
E013.1 Activities involving laundry
E013.2 Activities involving vacuuming
E013.3 Activities involving ironing
E013.4 Activities involving floor mopping and cleaning
E013.5 Activities involving residential relocation
E013.8 Other personal hygiene activity
E013.9 Other household maintenance
E014.0 Caregiving involving bathing
E014.1 Caregiving involving lifting
E014.9 Other activity involving person providing caregiving
E015.0 Activities involving food preparation and clean up
E015.1 Activities involving grilling and smoking food
E015.2 Activities involving cooking and baking
E015.9 Other activity involving cooking and grilling
E016.0 Activities involving digging, shoveling and raking
E016.1 Activities involving gardening and landscaping
E016.2 Activities involving building and construction
E016.9 Other activity involving property and land
maintenance, building and construction
E017.0 Activities involving roller coaster riding
E017.9 Other activity involving external motion
E018.0 Activities involving piano playing
E018.1 Activities involving drum and other percussion instrument playing
E018.2 Activities involving string instrument playing
E018.3 Activities involving winds and brass instrument playing
E019.0 Activities involving walking an animal
E019.1 Activities involving milking an animal
E019.2 Activities involving grooming and shearing an animal
E019.9 Other activity involving animal care
E029.0 Refereeing a sports activity
E029.1 Spectator at an event
E029.2 Rough housing and horseplay
E029.9 Other activity
E030
Unspecified activity
E830.7 Accident to watercraft causing submersion, occupant of
military watercraft, any type
2.10 Definitions of Medicare Code Edits
October 2009
Preliminary
06/12/09
E831.7 Accident to watercraft causing other injury, occupant
of military watercraft, any type
E832.7 Other accidental submersion or drowning in water transport accident, occupant of military watercraft, any type
E833.7 Fall on stairs or ladders in water transport, occupant of
military watercraft, any type
E834.7 Other fall from one level to another in water transport,
occupant of military watercraft, any type
E835.7 Other and unspecified fall in water transport, occupant of
military watercraft, any type
E836.7 Machinery accident in water transport, occupant of military watercraft, any type
E837.7 Explosion, fire, or burning in watercraft, occupant of military watercraft, any type
E838.7 Other and unspecified water transport accident, occupant
of military watercraft, any type
E876.6 Performance of operation (procedure) on patient not
scheduled for surgery
E876.7 Performance of correct operation (procedure) on wrong
side/body part
E928.7 Environmental and accidental causes, mechanism or
component of firearm and air gun
E990.1 Injury due to war operations from flamethrower
E990.2 Injury due to war operations from incendiary bullet
E990.3 Injury due to war operations from fire caused indirectly
from conventional weapon
E991.4 Injury due to war operations by fragments from
munitions
E991.5 Injury due to war operations by fragments from person-borne improvised explosive device
E991.6 Injury due to war operations by fragments from
vehicle-borne improvised explosive device (IED)
E991.7 Injury due to war operations by fragments from other
improvised explosive device (IED)
E991.8 Injury due to war operations by fragments from weapons
E992.0 Injury due to torpedo
E992.1 Injury due to depth charge
E992.2 Injury due to marine mines
E992.3 Injury due to sea-based artillery shell
E992.8 Injury due to war operations by other marine weapons
E992.9 Injury due to war operations by unspecified marine
weapon
E993.0 Injury due to war operations by aerial bomb
E993.1 Injury due to war operations by guided missile
E993.2 Injury due to war operations by mortar
E993.3 Injury due to war operations by person-borne improvised
explosive device (IED)
October 2009
Code list changes 2.11
06/12/09
Preliminary
E993.4 Injury due to war operations by vehicle-borne improvised
explosive device (IED)
E993.5 Injury due to war operations by other improvised explosive device (IED)
E993.6 Injury due to war operations by unintentional
detonation of own munitions
E993.7 Injury due to war operations by unintentional
discharge of own munitions launch device
E993.8 Injury due to war operations by other specified explosion
E993.9 Injury due to war operations by unspecified explosion
E994.0 Injury due to war operations by destruction of aircraft
due to enemy fire or explosives
E994.1 Injury due to war operations by unintentional destruction
of aircraft due to own onboard explosives
E994.2 Injury due to war operations by destruction of aircraft
due to collision with other aircraft
E994.3 Injury due to war operations by destruction of aircraft
due to onboard fire
E994.8 Injury due to war operations by other destruction of
aircraft
E994.9 Injury due to war operations by unspecified destruction
of aircraft
E995.0 Injury due to war operations by unarmed hand-to-hand
combat
E995.1 Injury due to war operations, struck by blunt object
E995.2 Injury due to war operations by piercing object
E995.3 Injury due to war operations by intentional restriction of
air and airway
E995.4 Injury due to war operations by unintentional drowning
due to inability to surface or obtain air
E995.8 Injury due to war operations by other forms of conventional warfare
E995.9 Injury due to war operations by unspecified form of conventional warfare
E996.0 Injury due to war operations by direct blast effect of
nuclear weapon
E996.1 Injury due to war operations by indirect blast effect of
nuclear weapon
E996.2 Injury due to war operations by thermal radiation effect
of nuclear weapon
E996.3 Injury due war operations by nuclear radiation effects
E996.8 Injury due to war operations by other effects of nuclear
weapons
E996.9 Injury due to war operations by unspecified effect of
nuclear weapon
E997.3 Injury due to war operations by weapon of mass destruction (WMD), unspecified
2.12 Definitions of Medicare Code Edits
October 2009
Preliminary
06/12/09
E998.0 Injury due to war operations but occurring after cessation of hostilities by explosion of mines
E998.1 Injury due to war operations but occurring after cessation of hostilities by explosion of bombs
E998.8 Injury due to other war operations but occurring after
cessation of hostilities
E998.9 Injury due to unspecified war operations but occurring
after cessation of hostilities
Bilateral Procedures
The following codes from MDC 8 were added to the list of
diagnosis codes used in evaluating for bilateral procedures:
209.73 Secondary neuroendocrine tumor of bone
274.00 Gouty arthropathy, unspecified
274.01 Acute gouty arthropathy
274.02 Chronic gouty arthropathy without mention of tophus
(tophi)
274.03 Chronic gouty arthropathy with tophus (tophi)
279.41 Autoimmune lymphoproliferative syndrome
279.49 Autoimmune disease, not elsewhere classified
813.46 Torus fracture of ulna (alone)
813.47 Torus fracture of radius and ulna
832.2 Nursemaid's elbow
The following codes were removed:
274.0 Gouty arthropathy
279.4 Autoimmune disease, not elsewhere classified
New edit
Wrong Procedure Performed
Certain E-codes indicate that the wrong procedure was
performed.
The following codes were added:
E8765 Performance of wrong operation (procedure) on
correct patient
E8766 Performance of operation (procedure) on patient not
scheduled for surgery
E8767 Performance of correct operation (procedure) on wrong
side/body part
October 2009
Code list changes 2.13
06/12/09
2.14 Definitions of Medicare Code Edits
Preliminary
October 2009
Preliminary
06/12/09
Index
maternity diagnoses, 1.9
newborn diagnoses, 1.5
non-covered procedure, 1.51
non-open biopsy procedure, 1.53
open biopsy procedure, 1.53
pediatric diagnoses, 1.8
procedures allowed for females only, 1.32
procedures allowed for males only, 1.37
questionable admission, 1.41
unacceptable principal diagnosis, 1.43
valid discharge status, 1.55
A
Adult
age categories, 1.4
diagnosis codes, 1.18
Age categories, 1.4
adult, 1.4
maternity, 1.4
newborn, 1.4
pediatric, 1.4
Age conflict, 1.4
adult diagnosis codes, 1.18
maternity diagnosis codes, 1.9
newborn diagnosis codes, 1.5
pediatric diagnosis codes, 1.8
B
Bilateral procedure, 1.54
C
Code lists, 1.1
Codes
adult diagnoses, 1.18
age conflict, 1.5, 1.8, 1.9, 1.18
diagnoses allowed for females only, 1.20
diagnoses allowed for males only, 1.35
limited coverage, 1.56
manifestations not allowed as principal dx, 1.38
October 2009
D
Diagnoses allowed for females only codes, 1.20
Diagnoses allowed for males only codes, 1.35
Duplicate of PDX, 1.4
example, 1.4
E
E-code as principal diagnosis, 1.4
E-codes, 1.4
Edit list, 1.3
Edits
age conflict, 1.4
bilateral procedure, 1.54
duplicate of PDX, 1.4
E-code as principal diagnosis, 1.4
invalid age, 1.55
Index
I.1
06/12/09
Preliminary
invalid discharge status, 1.55
invalid sex, 1.55
limited coverage, 1.56
manifestation code as principal diagnosis, 1.38
new edit, 2.13
non-covered procedure, 1.50
open biopsy check, 1.53
questionable admission, 1.41
requires secondary diagnosis, 1.42
sex conflict, 1.19
unacceptable principal diagnosis, 1.42
wrong procedure performed, 1.57
Example
duplicate of PDX, 1.4
P
I
R
Invalid age, 1.55
Invalid discharge status, 1.55
Invalid sex, 1.55
Requires secondary diagnosis, 1.42
Pediatric
age categories, 1.4
diagnosis codes, 1.8
Procedures allowed for females only codes, 1.32
Procedures allowed for males only codes, 1.37
Procedures, wrong procedure performed, 1.57, 2.13
Q
Questionable admission, 1.41
codes, 1.41
S
Limited coverage, 1.56
codes, 1.56
List of edits, 1.3
Sex conflict, 1.19
diagnoses allowed for females only codes, 1.20
diagnoses allowed for males only codes, 1.35
procedures allowed for females only codes, 1.32
procedures allowed for males only codes, 1.37
M
U
Manifestation code as principal diagnosis, 1.38
Manifestations not allowed as principal dx codes, 1.38
Maternity
age categories, 1.4
diagnosis codes, 1.9
UB-04 discharge status code list, 1.55
Unacceptable principal diagnosis, 1.42
codes, 1.43
L
V
N
Newborn
age categories, 1.4
diagnosis codes, 1.5
Non-covered procedure, 1.50
codes, 1.51
Non-open biopsy procedure codes, 1.53
Valid discharge status codes, 1.55
W
Wrong procedure performed, 1.57, 2.13
O
Open biopsy check, 1.53
codes, 1.53
I.2 Definitions of Medicare Code Edits
October 2009