CEDI Top 15 5010A1 Edits General Information This document provides a list of the top 15 edits received by CEDI Trading Partners during the submission of production ANSI X12 837 version 5010A1 claims. The edits are listed in numerical order by the first CSC in the edit. As a reminder, edits listed in the Edits Received on the 277CA column can be triggered by more than one issue. We have attempted to include all reasons that may cause the edit with the most “frequently received” as the first explanation. These edits will be updated monthly to provide you with accurate information. This document is intended to be used as a reference in addition to the CMS 5010 Edit Spreadsheet located on the CMS Web site http://www.cms.gov at the following link: http://www.cms.gov/MFFS5010D0/20_TechnicalDocumentation.asp. Edit List Table of Contents CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC CSCC A7: A7: A7: A8: A7: A7: A8: A7: A7: A7: A7: A7: A7: A8: A7: CSC CSC CSC CSC CSC CSC CSC CSC CSC CSC CSC CSC CSC CSC CSC 164: EIC IL ............................................................................................................................................ 2 187 ....................................................................................................................................................... 3 254 ....................................................................................................................................................... 3 306 ....................................................................................................................................................... 4 453 ....................................................................................................................................................... 5 480 ....................................................................................................................................................... 5 496: EIC 85 ........................................................................................................................................... 6 500: EIC DK ........................................................................................................................................... 7 500: EIC IL ........................................................................................................................................... 7 507 ....................................................................................................................................................... 7 510: CSC 187 ......................................................................................................................................... 8 562: EIC 82 ........................................................................................................................................... 9 562: EIC 85 ........................................................................................................................................... 9 562: CSC 128: EIC 85 ........................................................................................................................... 10 698 ..................................................................................................................................................... 11 Last Revision: November 11, 2014 Page 1 of 11 CEDI Top 15 5010A1 Edits The Edit Reference column is organized in the following fashion: (TR3 document.Page #.Loop.Segment & Element.Sequence #) Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 164: "Entity's contract/member number" EIC IL: Subscriber Edit Logic General Description If Medicare IDs: 2010BA.NM109 must be 10 11 positions in the format of NNNNNNNNNA or NNNNNNNNNAA or NNNNNNNNNAN where “A” represents an alpha character and “N” represents a numeric digit. OR If Railroad IDs: 2010BA.NM109 must be 7 - 12 positions in the format of ANNNNNN, AANNNNNN, ANNNNNNNNN, AANNNNNNNNN, AAANNNNNN, or AAANNNNNNNNN where “A” represents an alpha character and “N” represents a numeric digit. The subscriber HICN is invalid. Verify the HICN is entered exactly as it appears on the beneficiary's red, white, and blue Medicare card. If Medicare ID: Subscriber Primary Identifier must be 10 - 11 positions in the format of NNNNNNNNNA or NNNNNNNNNAA or NNNNNNNNNAN where “A” represents an alpha character and “N” represents a numeric digit. -ORIf Railroad ID: Subscriber Primary Identifier must be 7 - 12 positions in the format of ANNNNNN or AANNNNNN or ANNNNNNNNN or AANNNNNNNNN or AAANNNNNN or AAANNNNNNNNN where “A” represents an alpha character and “N” represents a numeric digit. Last Revision: November 11, 2014 Page 2 of 11 Edit Reference X222.121.2010BA.NM109.020 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 187: "Date(s) of service" Edit Logic General Description Reject the claim if 2400.DTP02 = "RD8" and the first date is not = the second date and SV101-2 is not "E0935" or "E0936", & the proc option "GL" or "IS" does NOT exist, & the proc option "DF", "DI", "DR", "LP", "OC", "OG", "OL" or "OP does exist. Reject the claim if 2400.DTP02=D8 or 2400.DTP02 = RD8 and the CCYYMM portion of the first date and the CCYYMM portion of the second date are equal and 2400.SV101-3, SV101-4, SV101-5 or SV101-6 = "RR" and 2400.SV104 is not = "1". The procedure code submitted for this line does not allow for spanned dates of service. Verify the start/from and end/to dates for this line are equal. X222.380.2400.DTP03.090 The number of services entered for this line is invalid. In general, rentals can only have one unit of service. Questions regarding proper billing policy of rental items should be directed to the DME MAC where the claim would be processed based on the patient’s state code in the address provided on the claim. If Date Time Period Format Qualifier is RD8, the "From" date service must be a date prior to the "To" date of service provided. The diagnosis code pointed to by diagnosis code pointer 1 (SV107‐1, SV107-2, SV107-3, or SV107-4) is invalid for the claim line date of service. X222.380.2400.DTP03.070 If 2400.DTP02 is RD8, the first date listed in 2400.DTP03 must be a date prior to the second date listed in 2400.DTP03. CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 254: "Primary diagnosis code" If 2400.SV107-1, SV107-2, SV107-3, or SV107-4 is "1" and 2300.HI01-1 is "BK" then 2300.HI01-2 must be a valid ICD-9-CM Diagnosis code on the date in 2400.DTP03 when Last Revision: November 11, 2014 Page 3 of 11 Edit Reference X222.380.2400.DTP03.060 X222.226.2300.HI01-2.030 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 306: Detailed description of service Edit Logic General Description DTP01 = "472", based on the ICD-9-CM Diagnosis Code list. Questions regarding the effective dates of a diagnosis code should be directed to the DME MAC where the claim would be processed based on the patient’s state code in the address provided on the claim. If 2400.SV107-1, SV107-2, SV107-3 & SV107-4 are not "1" and 2300.HI01-1 is "BK", 2300.HI01-2 must be a valid ICD-9-CM Principal Diagnosis code for every date in the DOS range for this claim based on the CMS subset of the ICD-9CM Diagnosis Code list. The first diagnosis code's effective dates fall entirely outside the claim’s dates of service. Questions regarding the effective dates of a diagnosis code should be directed to the DME MAC where the claim would be processed based on the patient’s state code in the address provided on the claim. Description must be present when Procedure Code requires a description/additional information. 2400.SV101-7 must be present when 2400.SV101-2 is present on the table of procedure codes that require a description. Last Revision: November 11, 2014 Page 4 of 11 Edit Reference X222.226.2300.HI01-2.070 X222.351.2400.SV101-7.020 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 453: "Procedure Code Modifier(s) for Service(s) Rendered" CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 480: "Other Carrier Claim filing indicator is missing or invalid" Edit Logic General Description 2400.SV101-3 must be valid procedure modifier on the date in 2400.DTP03 when DTP01 = "472". Procedure Modifier must be valid for the Service Date. (DTP01 = "472") X222.351.2400.SV101-3.010 X222.351.2400.SV101-3.020 2400.SV101-4 must be valid procedure modifier on the date in 2400.DTP03 when DTP01 = "472". 2400.SV101-5 must be valid procedure modifier on the date in 2400.DTP03 when DTP01 = "472". 2400.SV101-6 must be valid procedure modifier on the date in 2400.DTP03 when DTP01 = "472". 2320.SBR09 must not = "MA" or "MB". Procedure Modifier must be valid for the Service Date. (DTP01 = "472") X222.351.2400.SV101-4.020 Procedure Modifier must be valid for the Service Date. (DTP01 = "472") X222.351.2400.SV101-5.020 Procedure Modifier must be valid for the Service Date. (DTP01 = "472") X222.351.2400.SV101-6.020 Claim Filing Indicator Code must not = "MA" or "MB". Non-Medicare insurances will need to choose a valid code for the type of insurance being included in the claim file. "MA" and "MB" are not valid for NonMedicare insurances. X222.295.2320.SBR09.020 Last Revision: November 11, 2014 Page 5 of 11 Edit Reference CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A8: “Acknowledgement / Rejected for relational field in error” CSC 496: "Submitter not approved for electronic claim submissions on behalf of this entity." EIC 85: Billing Provider Edit Logic General Description 2010AA.NM109 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. The Billing Provider NPI not associated with submitter. The Trading Partner/Submitter ID is not authorized to submit claims for the supplier. If this error is received, the supplier must complete and sign the appropriate form on the CEDI Web site (www.ngscedi.com) and return to CEDI for processing. Suppliers who use a third party (e.g. a clearinghouse or billing service) must complete the Supplier Authorization Form. Suppliers who submit their own claims and do not use a third party biller must complete the CMS EDI Enrollment Agreement. Payer Additional Identifier billing provider must be "associated" to the submitter NPI. 2010BB.REF02 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. Last Revision: November 11, 2014 Page 6 of 11 Edit Reference X222.087.2010AA.NM109.050 X222.140.2010BB.REF02.075 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 500: "Entity's Postal/Zip Code" EIC DK: Ordering Physician CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 500: "Entity's Postal/Zip Code" EIC IL: Subscriber CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 507: "HCPCS" Edit Logic General Description Edit Reference 2420E.N403 must be a valid Zip Code. Ordering Provider Postal Zone ZIP Code must be a valid US Postal Service Zip Code. X222.458.2420E.N403.020 2010BA.N403 must be a valid postal/zip Code Subscriber Postal Zone or ZIP Code must be a valid US Postal Service Zip Code. X222.125.2010BA.N403.020 When 2400.SV101-1 = "HC", 2400.SV101-2 must be a valid HCPCS Code on the date in 2400.DTP03 when DTP01 = "472". When Product or Service ID Qualifier = "HC", the Procedure Code must be a valid HCPCS Code for the Service Date. (DTP01 = "472"). The HCPCS can be verified with PDAC. If additional information is needed concerning the valid combination, please contact the Jurisdiction where the claim will be processed. The HCSPCS must be valid for the date of service and the modifiers attached must be a valid combination. Verify that all required modifiers are sent if X222.351.2400.SV101-2.020 When 2400.SV101-1 = "HC", 2400.SV101-2 must be a valid HCPCS Code on the date in 2400.DTP03 when DTP01 = "472". OR Last Revision: November 11, 2014 Page 7 of 11 X222.351.2400.SV101-2.030 CEDI Top 15 5010A1 Edits Edits Received on the 277CA Edit Logic When 2400.SV101-1 = "HC", 2400.SV101-2 must be a valid HCPCS Code from the DME subset on the date in 2400.DTP03 when DTP01 = "472". When 2400.HCP09 = "HC", 2400.HCP10 must be a valid HCPCS Code on the date in 2400.DTP03 when DTP01 = "472". CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 510: "Future date" CSC 187: "Date(s) of service" When 2400.DTP02 = RD8 and the second date is a future date, one of the following proc options must exist for the procedure: "IS", "PA", "PE", "PI", "PK", "PL", "PP", "PS" or "PX". If 2400.DTP02 is D8,2400.DTP03 must not be a future date. Last Revision: November 11, 2014 Page 8 of 11 General Description modifiers are required. The HCPCS can be verified with PDAC. If additional information is needed concerning the valid combination, please contact the Jurisdiction where the claim will be processed. When Product or Service ID Qualifier = "HC", Procedure Code must be a valid HCPCS Code on the Date of Service when DTP01 = "472". The service end/to date is greater than the date this claim was received. Questions regarding proper billing policy should be directed to the DME MAC where the claim would be processed based on the patient’s state code in the address provided on the claim. If Date Time Period Format Qualifier is D8, Service Date must not be a future date. Edit Reference X222.416.2400.HCP10.020 X222.380.2400.DTP03.080 X222.380.2400.DTP03.040 CEDI Top 15 5010A1 Edits Edits Received on the 277CA Edit Logic General Description If 2400.DTP02 is RD8, the first date listed in 2400.DTP03 must not be a future date. If Date Time Period Format Qualifier is RD8, the "From" date of service must not be a future date. X222.380.2400.DTP03.050 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 562: " Entity's National Provider Identifier (NPI)” EIC 82: Rendering Provider 2420A.NM109 must be valid according to the NPI algorithm. Rendering Provider Identifier must be a valid NPI on the Crosswalk when evaluated with Receiver Primary Identifier. Medicare DME claims do not require the Rendering Provider information to be sent. It is recommended that the information is removed from the claim. For more information on how to remove the information, please contact your software vendor, billing service, or clearinghouse. X222.262.2310B.NM109.030 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 562: "Entity's National Provider Identifier (NPI)" EIC 85: Billing Provider 2010AA.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109. Billing Provider Identifier must be a valid NPI on the Crosswalk. Verify that the NPI and DME PTAN are linked together. To establish a crosswalk, verify the supplier's information listed on the NPPES web site matches the X222.087.2010AA.NM109.030 Last Revision: November 11, 2014 Page 9 of 11 Edit Reference CEDI Top 15 5010A1 Edits Edits Received on the 277CA Edit Logic General Description Edit Reference information at the NSC. If you have questions about these matches please contact NPPES at 800-4653203 or the NSC at 866238-9652. Note: PECOS can also affect your crosswalk. PECOS is the system used by the NSC for DME suppliers to enroll in Medicare. Suppliers can log in to and verify that their NPI is listed correctly. For assistance with PECOS, call 866-4848049. CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC 85: Billing Provider 2010AA.NM109 must be valid according to the NPI algorithm. Billing Provider Identifier must be a valid NPI. X222.087.2010AA.NM109.020 The first position of 2010AA.NM109 must be a "1". The first position of Billing Provider NPI must be a "1". X222.087.2010AA.NM109.040 2010AA.REF must be associated with the provider identified in 2010AA.NM109 Billing Provider Tax Identification Number must be associated with the billing provider's NPI. Verify that the information you are submitting matches the information on file with the NPPES and NSC. X222.094.2010AA.REF02.050 Last Revision: November 11, 2014 Page 10 of 11 CEDI Top 15 5010A1 Edits Edits Received on the 277CA CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 698: "Form Type Identifier." Edit Logic General Description 2440.LQ02 must be a valid form for the procedure code in 2400.SV102. The CMN form number must be a valid form for the procedure code. Edit Reference X222.492.2440.LQ02.030 Questions regarding the CMN form number should be directed to the DME MAC where the claim would be processed based on the patient’s state code in the address provided on the claim. 2440.LQ02 must be a valid DMERC CMN Form. The CMN form number must be a valid DMERC CMN Form. X222.492.2440.LQ02.020 Questions regarding the CMN form number should be directed to the DME MAC where the claim would be processed based on the patient’s state code in the address provided on the claim. If 2400.PWK with PWK01 = "CT" and PWK02 = "AD" is present, 2440.LQ must be present. Last Revision: November 11, 2014 Page 11 of 11 If DME Certificate of Medical Necessity Indicator with PWK01 = "CT" and PWK02 = "AD" is present, the CMN form number must be present. X222.492.2440.LQ.030
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