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Current NGS-ACE Edits
The current smart edits are listed below. We’ve provided the edit messages along with their description and valuable resources for each of the NGS-ACE edits.
| Current NGS-ACE Edits |
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| Smart Edits Number: mONPN_23955 Message: Per Medicare CPT/HCPCS, code XXXXX must have modifier GN. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Claims containing any of the “always therapy” codes must have one of the therapy modifiers appended (GN, GO, GP). In addition, when any code on the list of therapy codes is submitted with specialty codes “65” (physical therapist in private practice), “67” (occupational therapist in private practice), or “15” (speech-language pathologist in private practice) they always represent therapy services, because they are provided by therapists. Annual CRs update the list of codes that are described as “sometimes” or “always” therapy services. This will include additions, changes and deletions to the therapy code list. The current and previous therapy code listings can be found on CMS' Therapy Services web page. For additional guidance review: |
| Smart Edits Number: 112LN Message: Procedure code 93668 requires a payable diagnosis code and an applicable diagnosis code pointer. Please review NCD 20.35 for additional information. Description: Procedure code 93668 does not include a payable diagnosis code and an applicable diagnosis code pointer. Resources: Effective for services performed on or after 5/25/2017, the CMS has determined that the evidence is sufficient to cover SET for beneficiaries with IC for the treatment of symptomatic PAD. For additional guidance review: |
| Smart Edits Number: 099DN Message: Procedure code G0445 requires a payable diagnosis code and applicable diagnosis pointer. Description: Procedure code G0445 must be billed with a payable diagnosis code and applicable diagnosis code pointer. Resources: Effective for claims with dates of service on or after 11/8/2011, CMS will cover up to two individual 20- to 30-minute, face-to-face counseling sessions annually for Medicare beneficiaries for HIBC to prevent Screening for STI, for all sexually active adolescents, and for adults at increased risk for STIs, if referred for this service by a primary care physician or practitioner, and provided by a Medicare eligible primary care provider in a primary care setting. Coverage of HIBC to prevent STIs is consistent with the USPSTF recommendation. For additional guidance review: |
| Smart Edits Number: 130LN Message: Procedure code XXXXX must be billed with a payable diagnosis code and applicable diagnosis code pointer. Please see NCD 30.3.3 for additional information. Description: Procedure code 97810, 97811, 97813, 97814, 20560 or 20561 must include a payable diagnosis code and applicable diagnosis code pointer. Resources: Effective for claims with dates of service on and after 1/21/2020, acupuncture is only covered for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act (the Act). Medicare reimbursement for acupuncture, as an anesthetic, or as an analgesic or for other therapeutic purposes, may not be made unless the specific indication is excepted. All indications for acupuncture outside of NCD section 30.3.3 remain noncovered. For additional guidance review: |
| Smart Edits Number: mFRN (51033) Message: Per Medicare guidelines, audiology service code XXXXX billed with modifier AB by an audiologist has exceeded the allowed frequency of once per 12 months. Description: Audiology service code billed with modifier AB exceeded the allowed frequency of once per 12 months. Resources: As defined in the Social Security Act, section 1861, (ll)(3), the term “audiology services” specifically means hearing and balance assessment services furnished by a qualified audiologist. Hearing and balance assessment services are termed “audiology services” regardless of whether they are furnished by an audiologist, physician, NPP or hospital. Billing and coding requirements for these diagnostic tests using the AB modifier are as follows:
For additional guidance review: |
| Smart Edits Number: NPSN Message: A nonphysician provider with taxonomy code XXXXXXXXXX has reported E/M code XXXXX in lieu of another procedure code that more accurately defines the service provided. Description: A nonphysician provider is not allowed to bill E/M codes. Resources: In order to receive payment from Medicare for E/M services, your state must allow you to bill for E/M services within your scope of practice. For additional guidance review: |
| Smart Edits Number: CSIN Message: Claim status is available via the J6 IVR please call 877-908-9499 option 2/4 or on the NGSConnex portal, go to NGSMedicare.com. You must create an account (it is free) if you do not have a log in. Description: Informational Message - Reminder to call the IVR or go to the NGSConnex portal for claim status information. Resources: CMS requires all MACs to offer provider self-service tools and for providers to utilize these tools. Therefore, NGS developed the following tools to assist providers with general inquires and much more. NGSConnex is a free, secure, web-based application developed by NGS just for you! NGSConnex provides access to a wide array of self-service functions that save you time and money, such as:
For additional guidance review: |
| Smart Edits Number: ELGIN Message: As a reminder, beneficiary eligibility can be obtained via the J6 IVR at 877-908-9499 option 1 or on the NGSConnex portal go to NGSMedicare.com. You must create an account (it is free) if you do not have a log in. Description: Informational Message - Reminder to call the IVR or go to the NGSConnex portal for bene eligibility information. Resources: CMS requires all MACs to offer provider self-service tools and for providers to utilize these tools. Therefore, NGS developed the following tools to assist providers with general inquires and much more. NGSConnex is a free, secure, web-based application developed by NGS just for you! NGSConnex provides access to a wide array of self-service functions that save you time and money, such as:
For additional guidance review: |
| Smart Edits Number: APPIN Message: Appeals and redetermination information is available on the J6 IVR at 877-908-9499 option 7 or on the NGSConnex portal go to NGSMedicare.com. You must create an account (it is free) if you do not have a log in. Description: Informational Message – Reminder to call the IVR or go to the NGSConnex portal for appeals and redetermination information. Resources: CMS requires all MACs to offer provider self-service tools and for providers to utilize these tools. Therefore, NGS developed the following tools to assist providers with general inquires and much more. NGSConnex is a free, secure, web-based application developed by NGS just for you! NGSConnex provides access to a wide array of self-service functions that save you time and money, such as:
For additional guidance review: |
| Smart Edits Number: ADRIN Message: NGS is waiting on a response to an ADR for one or more claims for provider XXXXXXXXXX. Please refer to your ADR letter(s) for details. ADR status is available on the NGSConnex portal (www.NGSMedicare.com). You must create a free account if you do not have one. Description: Informational Message - Reminder to respond to an ADR requesting additional information. Go to the NGSConnex portal at NGSMedicare.com for the ADR status. Resources: NGSConnex is a free, secure, web-based application developed by NGS just for you! NGSConnex provides access to a wide array of self-service functions that save you time and money, such as:
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| Smart Edits Number: 083LN Message: Procedure code 33340 must be submitted with a required diagnosis code and an applicable diagnosis code pointer. Please see NCD 20.34 for additional information. Description: Procedure code 33340 must be submitted with a required diagnosis code and an applicable diagnosis code pointer. Please see NCD 20.34 for additional information. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 085LN Message: Procedure code 33340 must be submitted with a required diagnosis code and an applicable diagnosis code pointer. Please see NCD 20.34 for additional information. Description: Procedure code 33340 must be submitted with a required diagnosis code and an applicable diagnosis code pointer. Please see NCD 20.34 for additional information. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 035DN Message: Procedure code XXXXX must be billed with a specific diagnosis code and applicable diagnosis code pointer. Description: Procedure code XXXXX must be billed with a specific diagnosis code and applicable diagnosis code pointer. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: mPTN Message: Per Medicare guidelines, procedure code XXXXX is a therapy service. No payment is made if provided in place of service XX. Description: Per Medicare guidelines, procedure code XXXXX is a therapy service. No payment is made if provided in place of service XX. Resources: Therapy services are a covered benefit in Sections 1861(g), 1861(p), and 1861(ll) of the Act. Therapy services may also be provided incident to the services of a physician or NPP under Sections 1861(s)(2) and 1862(a)(20) of the Act. Covered therapy services are furnished by providers, by others under arrangements with and under the supervision of providers, or furnished by suppliers (e.g., physicians, NPP, enrolled therapists), who meet the requirements in Medicare manuals for therapy services and must be considered skilled in nature. Coverage of outpatient physical therapy and occupational therapy under Part B includes the services of a qualified therapist in private practice when furnished in the therapist’s office or the beneficiary’s home. For this purpose, “home” includes an institution that is used as a home, but not a hospital, CAH or SNF, (Federal Register, Vol 63, No. 211, pg. 58869, Nov. 2, 1998). Where a PPS applies, therapy services are paid when services conform to the requirements of those PPS. Reimbursement for therapy provided to Part A inpatients of hospitals or residents of SNFs in covered stays is included in the respective PPS rates. Payment for therapy provided by an HHA under a plan of treatment is included in the home health PPS rate. Therapy may be billed by an HHA on TOB 34X if there are no home health services billed under a home health plan of care at the same time (e.g., the patient is not homebound), and there is a valid therapy plan of treatment. For additional guidance review: |
| Smart Edits Number: POSMaN Message: Place of service code 24 is required with servicing provider taxonomy code XXXXXX. Description: Place of service code 24 is required with servicing provider taxonomy code XXXXXX. Resources: Place of service codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. CMS maintains POS codes used throughout the health care industry. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For additional guidance review: |
| Smart Edits Number: mONPN_24110 Message: Per Medicare CPT/HCPCS code Current adjusted procedure code must have modifier GO. Description: Medicare Always Therapy - Occupational Therapy Only (Added Taxonomy Codes). Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Claims containing any of the “always therapy” codes must have one of the therapy modifiers appended (GN, GO, GP). CPT codes designated as “sometimes therapy” permits physicians and certain NPPs, including nurse practitioners, physician assistants, and clinical nurse specialists, to furnish these services outside a therapy plan of care when appropriate. When furnished by therapists, these "sometimes therapy" services are “always therapy,” which means they must be accompanied by the appropriate therapy modifier, GP, GO or GN, to reflect that it is under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively. Annual CRs update the list of codes that are described as “sometimes” or “always” therapy services. This will include additions, changes and deletions to the therapy code list. The current and previous therapy code listings can be found on CMS’ Therapy Services web page. For additional guidance review: |
| Smart Edits Number: mOD4 Message: Per Medicare guidelines, individual component HCPCs codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCs code XXXXX is a component code of organ or disease-oriented panel 80053. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Description: Per Medicare guidelines, individual component HCPCs codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCs code XXXXX is a component code of organ or disease-oriented panel 80053. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Resources: |
| Smart Edits Number: 008LN Message: Procedure code XXXXX in POS XX an appropriate diagnosis code and diagnosis code pointer are required. Please see NCD 110.4 for additional information. Description: Procedure code 36522 and POS is 11, 19, 21 or 22 must include a payable diagnosis code and diagnosis pointer. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 019LN Message: Procedure code XXXXX requires an applicable diagnosis code and an appropriate diagnosis code pointer. Please see NCD 190.11 for additional information. Description: Procedure code G0248, G0249 and G0250 don't include a payable diagnosis code. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: KXIN Message: Reminder - for acupuncture billed over and above the initial 12 visits in 90 days, use of the KX modifier must be documented in order to justify medical necessity as per CMS guidelines and coverage/coding requirements. Description: Informational Message - Reminder for procedure codes 97810, 97811, 97813, 97814, 20560 and 20561 documentation may be required to justify medical necessity. Resources: |
| Smart Edits Number: 024LN Message: Procedure code XXXXX requires a specific diagnosis code and an applicable diagnosis code pointer. Please review NCD 210.1 for additional information. Description: Procedure code G0102, G0103 and diagnosis code Z125 is not included. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 056LN Message: Procedure code XXXXX requires a specific diagnosis code and an applicable diagnosis code pointer. Please review NCD 150.13 for additional information. Description: Procedure code 0275T, G0276 and diagnosis Z006 is not included. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 061LN Message: Procedure code XXXXX requires a specific diagnosis code and an applicable diagnosis code pointer. Please review NCD 220.4 for additional information. Description: Procedure code 77063 and diagnosis Z1231 is not included. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: mMUR Message: Per Medicare HCPCs code R0075 was billed without the required UN, UP, UQ, UR or US modifier. Description: Procedure code R0075 must be billed with the appropriate modifier. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. For additional guidance review: |
| Smart Edits Number: mONPN_24111 Message: Per Medicare CPT/HCPCS code Current adjusted procedure code must have modifier GP. Description: Physical Therapy codes provided by a physical therapist must include the appropriate modifiers. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Claims containing any of the “always therapy” codes must have one of the therapy modifiers appended (GN, GO, GP). CPT codes designated as “sometimes therapy” permits physicians and certain NPPs, including nurse practitioners, physician assistants, and clinical nurse specialists, to furnish these services outside a therapy plan of care when appropriate. When furnished by therapists, these "sometimes therapy" services are “always therapy,” which means they must be accompanied by the appropriate therapy modifier, GP, GO or GN, to reflect that it is under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively. Annual CRs update the list of codes that are described as “sometimes” or “always” therapy services. This will include additions, changes and deletions to the therapy code list. The current and previous therapy code listings can be found on CMS’ Therapy Services web page. For additional guidance review: |
| Smart Edits Number: mB50N Message: Per Medicare guidelines, a bilateral procedure code XXXXX submitted with modifier 50 and billed with more than 1 unit of service is inappropriate. Bilateral procedure billed with a modifier 50 should be billed with one unit of service. Description: Bilateral procedure codes submitted with modifier 50 should not be billed with more than 1 unit of service. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Bilateral indicator of 1 must be reported with 1 unit of service and modifier 50. The 50 modifier identifies the service as being performed on both sides of the body. Do not report anatomical modifiers in addition to modifier 50.
Note: NGS requires placement of pricing modifiers in the first modifier position to correctly price and process claims. Also, when submitting modifiers ensure there are no blanks in between the modifier fields. The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators. For additional guidance review: |
| Smart Edits Number: mOD7 Message: Per Medicare guidelines, individual component HCPCs codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCs code XXXXX is a component code of organ or disease-oriented panel 80051. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Description: Per Medicare guidelines, individual component HCPCs codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCs code XXXXX is a component code of organ or disease-oriented panel 80051. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Resources: Prior to Protecting Access to Medicare Act of 2014 (PAMA) implementation, CMS paid for certain chemistry tests using Automated Test Panels (ATPs) which used claims processing logic to apply a bundled rate to sets of these codes, depending on how many of these chemistry tests were ordered. Additionally, the claims processing system would not pay more than the associated panel Current Procedural Terminology (CPT) code if the tests were billed individually. This prior logic of using ATPs and rolling up payment amounts to not exceed the panel rate, no longer exists under PAMA guidelines. HCPCS codes include those from the AMA CPT Manual, that are in the category of Organ or Disease Oriented panels, which are panels that consist of groups of specified tests. Since, CMS no longer has payment logic to roll up panel pricing for organ or disease-oriented panels (also known as Automated Multi-Channel Chemistry or AMCC tests), laboratories must report the HCPCS code for the AMCC panel test where appropriate and not report separately the tests that make up that panel. For additional guidance review: MLN Matters® MM11248: Re-implementation of the AMCC Lab Panel Claims Payment |
| Smart Edits Number: p043LN Message: HCPCs XXXXX requires a payable diagnosis code and applicable diagnosis code pointer. Description: Procedure codes 86812, 86813, 86816, 86817, 86821, 86825, 86826 require a payable diagnosis code and diagnosis pointer. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: p045LN Message: Procedure code XXXXX requires a payable diagnosis code and an applicable diagnosis pointer. Description: Procedure codes 82438 and 89230 require a payable diagnosis code and diagnosis pointer. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: p048LN Message: Procedure code XXXXX requires a payable diagnosis code and an applicable diagnosis pointer. Description: Procedure codes 99406 and 99407 require a payable diagnosis code and diagnosis pointer. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: p098LN Message: Procedure code XXXXX with diagnosis code Z1159 requires an additional diagnosis code and appropriate diagnosis pointer. Description: Procedure code 86704, 86706, 87340 and 87341 with diagnosis code Z1159 must include an additional valid diagnosis code and appropriate diagnosis pointer. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 452BN7 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer Description: Codes 93975, 93976, 93978, 93979 DOS 5.01.22 to 09.30.2022 diagnosis required. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN8 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer Description: Codes 93985 & 93986 Diagnosis Required. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: MFX1N Message: The maximum frequency for the procedure code has been exceeded. The allowable maximum frequency for the procedure is one time per calendar month. Description: Procedure codes 99487, 99490 or 99491 is reported more than one time per calendar month. Resources: CMS recognizes CCM is a critical primary care service that contributes to better patient health and care. There are monthly billing limitations/frequency guidelines for these services. This would apply to services billed by the same provider or a different provider. For example, you can’t report complex CCM and non-complex CCM for the same patient in a calendar month. For additional guidance review: |
| Smart Edits Number: MFR 26876 Message: Per Medicare guidelines, the frequency does not meet policy requirements for the procedure code. Description: Procedure code G0402 exceeds the allowed frequency. Resources: Medicare does not allow more than one initial preventive examination. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For additional guidance review:
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| Smart Edits Number: mTCH Message: Per Medicare guidelines, procedure code XXXXX describes a diagnostic procedure that is not eligible for separate reimbursement in place of service XX. Description: Per Medicare guidelines, procedure code XXXXX describes a diagnostic procedure that is not eligible for separate reimbursement in place of service XX. Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For additional guidance review:
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| Smart Edits Number: mOD5 Message: Per Medicare guidelines, individual component HCPCS codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCS code XXXXX is a component code of organ or disease-oriented panel 80069. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Description: Per Medicare guidelines, individual component HCPCS codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCS code XXXXX is a component code of organ or disease-oriented panel 80069. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For additional guidance review: |
| Smart Edits Number: mOD6 Message: Per Medicare guidelines, individual component HCPCS codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCS code XXXXX is a component code of organ or disease-oriented panel 80061. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Description: Per Medicare guidelines, individual component HCPCS codes which comprise a specific organ or disease-oriented panel shall not be reported separately. HCPCS code XXXXX is a component code of organ or disease-oriented panel 80061. It is inappropriate to report all individual component codes on separate claim lines for the same beneficiary, performed on the same date of service on the same claim. Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For additional guidance review: |
| Smart Edits Number: mATN Message: Per Medicare guidelines procedure code XXXXX requires modifier GP, GO, or GN. Description: (mATN) Medicare Always Therapy The mATN edit fires when a therapy procedure code is submitted and required modifier GP, GO or GN is not on the detail line. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Modifiers may be used to indicate:
CPT codes designated as “sometimes therapy” permits physicians and certain NPPs, including nurse practitioners, physician assistants, and clinical nurse specialists, to furnish these services outside a therapy plan of care when appropriate. When furnished by therapists, these "sometimes therapy" services are “always therapy,” which means they must be accompanied by the appropriate therapy modifier, GP, GO or GN, to reflect that it is under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively. Annual CRs update the list of codes that are described as “sometimes” or “always” therapy services. This will include additions, changes and deletions to the therapy code list. The current and previous therapy code listings can be found on CMS’ Therapy Services web page. For additional guidance review: |
| Smart Edits Number: mEPON Message: Per Medicare guidelines, evaluation and management code XXXXX is not covered when reported by provider specialty XXXXXX. Description: Per Medicare guidelines, evaluation and management code XXXXX is not covered when reported by provider specialty XXXXXX. Resources: E/M services are professional face to face services rendered by a physician or NPP in various sites or POS. Medicare will pay for E/M services for specific, nonphysician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS), and certified nurse midwife (CNM), whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service; however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above nonphysician practitioners. Keep in mind. the service provided must be medically necessary, and the service must be within the scope of practice for a nonphysician practitioner in the State in which he/she practices. Medicare does not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice. For additional guidance review: |
| Smart Edits Number: p292DN Message: Procedure Code XXXXX is not medically necessary when billed with the EB modifier. Description: Procedure codes J0881, J0885 or Q5106 are reported with the EB modifier the edit will be generated. Resources: Erythropoiesis stimulating agents (ESAs) stimulate the bone marrow to make more red blood cells and are United States Food and Drug Administration (FDA) approved for use in reducing the need for blood transfusion in patients with specific clinical indications. The FDA has issued alerts and warnings for ESAs administered for a number of clinical conditions, including cancer. Published studies report a higher risk of serious and life-threatening events associated with oncologic uses of ESAs. Effective for claims with dates of service on and after 1/1/2008, non-ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EB (ESA, anemia, radio induced), shall be denied. For additional guidance review: |
| Smart Edits Number: p159BN Message: Procedure code XXXXX must be billed with a required diagnosis code and applicable diagnosis code pointer. Description: Procedure code 22510-22515 and diagnosis is not considered a payable diagnosis code. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN1 Message: Procedure code XXXXX requires an appropriate diagnosis code and applicable diagnosis code pointer. Description: Procedure code 93880 or 93882 must include a payable diagnosis code. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN2 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer. Description: Procedure code 93886, 93888, 93890, 93892 or 93893 are submitted without a payable diagnosis code. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN3 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer. Description: Procedure code 93922, 93923, 93924, 93925 or 93926 are submitted without a payable diagnosis code and the beginning date of service is on or after 10/1/2022. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN4 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer. Description: Procedure code 93922, 93923, 93924, 93925 or 93926 are submitted without a payable diagnosis code and the beginning date of service is on or after 3/10/2017 or on or before 9/30/2022. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN5 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer. Description: Procedure code 93970 or 93971 are submitted without a payable diagnosis code. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN6 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer. Description: Procedure codes 93975, 93976, 93978, 93979 DOS 10.01.2022 diagnosis required. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN9 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer. Description: Procedure code 93990 diagnosis required. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN10 Message: Procedure code XXXXX requires both a required diagnosis code and an appropriate diagnosis code pointer. Description: Procedure codes 93930 & 93931 diagnosis required. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 452BN1 Message: Procedure code XXXXX requires an appropriate diagnosis code and applicable diagnosis code pointer. Description: Procedure code 93880 or 93882 must include a payable diagnosis code. Resources: Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. For additional guidance review: |
| Smart Edits Number: 012fN2 Message: Required modifier missing for procedure code XXXXX when billed with diagnosis code XXXXX. Description: (012fN2) Cardiac Pacemakers missing KX Modifier The 012F edit fires when procedure code 33206, 33207 and 33208 are missing the KX modifier when billed with diagnosis code XXXXX. Resources: Visit the Medical Policy section of our website. You will find LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 012fN3 Message: Modifiers KX and SC are not allowed with procedure code XXXXX. Description: (012fN2) Cardiac Pacemakers KX and SC Modifiers The 012F edit fires when procedure code 33206, 33207 and 33208 are billed with modifiers KX or SC. Resources: Visit the Medical Policy section of our website. You will find LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 012fN5 Message: If procedure code XXXXX is billed with XX modifier then the appropriate diagnosis is required. Description: (012fN5) Cardiac pacemaker with KX modifier and without payable diagnosis. The 012fN5 edit is generated when procedure codes 33206, 33207 or 33208 are billed with the KX modifier without an appropriate diagnosis. Resources: Visit the Medical Policy section of our website. You will find LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: p451AN Message: Procedure code XXXXX has deemed to be excluded from payment "incident to" the physicians’ service as it is usually self-administered by the patient. Description: (p451AN) Self-Administered Drugs The p451AN edit is generated when a noncovered, self-administered drug, is furnished “incident to” the physicians’ service. Resources: The Medicare program provides limited benefits for outpatient drugs. The program covers drugs that are furnished “incident to” a physician's service provided that the drugs are not usually self-administered. Drugs that are usually self-administered by the patient, such as those in pill form, or are used for self-injection, are generally not covered by Part B. However, there are a limited number of self-administered drugs that are covered because the Medicare statute explicitly provides coverage. Visit the Medical Policy section of our website. You will find LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). For additional guidance review: |
| Smart Edits Number: pCON Message: Procedure code Modifier XX for an Occupational Therapist assistant requires the outpatient therapy plan of care modifier Description: (pCON) Modifiers CQ and CO not billed with required GP or GO modifiers The pCON edit is generated when claims billed with CQ/CO modifier are not paired with a plan of care modifier GP/GO. Resources: The CQ and CO modifiers must be used when applicable for all outpatient therapy services for which payment is made under section 1848 (the PFS) or section 1834(k) of the Social Security Act (the Act). As such, the modifiers are required to be used for therapy services furnished by providers that submit institutional claims, including the following provider types: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs). However, the CQ and CO modifiers are not applicable to claims from critical access hospitals or other providers that are not paid for outpatient therapy services under the PFS or section 1834(k) of the Act. The CQ modifier must be reported with the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims with modifiers not so paired will be rejected/returned as unprocessable. For additional guidance review: |
| Smart Edits Number: FCRP Rule 22965 Message: Procedure code XXXXX is a facility service code. This service is not to be reported on a professional claim. Description: (FCRP Rule 22965) Medicare Part A Code Denial The FCRP Rule 22965 edit is generated when a Medicare Part A procedure code is billed to Part B Medicare. Resources: Medicare Part A codes may not be paid by Medicare Part B. Standby services are not payable to physicians. Physicians may not bill Medicare or beneficiaries for standby services. Payment for standby services is included in the Part A payment to the facility. Such services are a part of hospital costs to provide quality care. If hospitals pay physicians for standby services, such services are part of hospital costs to provide quality care. For additional guidance review: |
| Smart Edit Number: FCRP Rule 23763 Message: Procedure code XXXXX is a facility service code. This service is not to be reported on a professional claim Description: (FCRP Rule 23763) Procedure to place of service error The FCRP Rule 23763 edit is generated when the detail Place of Service (POS) is not valid for the CPT/HCPC. Resources: Medicare Part B 101 Manual - Place of Service Codes |
| Smart Edits Number: mFR Rule 28693 Message: Per Medicare guidelines, the frequency doesn’t not meet policy requirements for the procedure code. Description: (mFR Rule 28693) Diabetes Screening Frequency The mFR Rule 28693 edit is generated when HCPCS codes 82947, 82950 is billed with diagnosis code Z131 for DOS on or after date of service 10/01/2015 more than once in a 12 month period. Resources: |
| Smart Edits Number: mIC Message: Per Medicare guidelines, procedure code XXXXX is a service covered incident to a physician’s service and modifier 26 or TC is not appropriate. Description: (mIC) Medicare Incident to Codes Procedure code is a service covered incident to a physician's service and modifier 26 or TC is not appropriate. Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For additional guidance review: |
| Smart Edits Number: SIP Message: Sequential intravenous push code 96376 reported this code may only be reported by facilities. This service is not to be reported on a professional claim Description: (SIP) Sequential Intravenous Push Reported by a Physician Sequential intravenous push code 96376 reported, this code may only be reported by facilities. Resources: The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such status code. For additional guidance review: |
| Smart Edits Number: POSaN Message: Procedure code XXXXX is not typically performed in an ASC setting. Description: (POSaN) Place of Service (POS) Code 24 Not Typical for Procedure Procedure code XXXXX is not typically performed in an ASC setting. Resources: ASC payment indicators are assigned to all ASC procedures. ASC Payment Rates include addenda’s. You can locate the addenda’s within the most recent quarterly files located on the ASC Payment Rates web page. For additional guidance related to POS review: Appendix 3: Place of Service Codes |
| Smart Edits Number: 176BN1 Message: Procedure code 82652 requires a payable diagnosis code. Description: (176BN1) Vitamin D Assay Testing Procedure code 82652 required diagnosis code is missing Resources: Visit the Medical Policy section of our website. You will find LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: MOD50aN Message: Modifier 50 is not recognized in an Ambulatory Surgical Center. Description: (MOD50aN) Modifier Invalid The MOD50aN edit is generated when modifier 50 is appended to a CPT/HCPC and the POS is 24. Resources: Payment for Multiple Procedures, a procedure performed bilaterally in one operative session is reported as two procedures, either as a single unit on two separate lines or with “2” in the units field on one line. The multiple procedure reduction of 50 percent applies to all bilateral procedures subject to multiple procedure discounting. For example, if lavage by cannulation; maxillary sinus (antrum puncture by natural ostium) (CPT code 31020) is performed bilaterally in one operative session, report 31020 on two separate lines or with “2” in the units field. Depending on whether the claim includes other services to which the multiple procedure discounts applies, the contractor applies the multiple procedure reduction of 50 percent to the payment for at least one of the CPT code 31020 payment rates. Therefore, bilateral procedures furnished in ASCs should be reported as either a single unit on two separate lines (appending the RT and LT modifiers) or with "2" in the units field on one line, in order for the bilateral procedures to be paid correctly. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting. Effective for services rendered on or after 3/26/2018, claims by ASCs inappropriately billed with a modifier 50 will be rejected. For additional guidance review: |
| Smart Edits Number: CATN Message: Procedure Code XXXXX is not allowed when performed by an optometrist. Exception: For post-operative care only, review our CPT Modifier 55 website article to determine if it is appropriate for this procedure. Description: (CATN) Optometrist Cannot Bill Service without 55 Modifier. Determines when an Optometrist (NPI) bills certain services without a 55 modifier. Resources: The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the preoperative, intra-operative and postoperative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:
Modifier 54 indicates that the surgeon is relinquishing all or part of the postoperative care to a physician.
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| Smart Edits Number: DMEN Message: Per the DMEPOS Jurisdiction List, code XXXXX should be submitted to the DME MAC. Description: (DMEN) Durable Medical Equipment The DMEN edit will set when a DME code is submitted to Part B. Resources: The DME MACs process Medicare Durable Medical Equipment, Orthotics, and Prosthetics (DMEPOS) claims for a defined geographic area or "jurisdiction," servicing suppliers of DMEPOS. For additional guidance and to obtain the proper DME contractor visit the CMS Who are the MACs webpage. |
| Smart Edits Number: f42N Message: The service has not been deemed a medical necessity; please review. Description: (f42N) Code Billed with Non-Covered Diagnosis The f42N edit will set when a procedure code is submitted with a non-covered diagnosis code. Resources: Medicare generally does not cover dental services. Since the inception of Medicare, dental services including routine dental care have been excluded as a benefit. Visit the CMS Medicare Coverage Data Base section for LCDs , related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). For additional guidance review: |
| Smart Edits Number: mM62hN rule 2808 Message: Modifier 62 is present on procedure code xxxxx on the current claim. The same procedure code without the modifier 62 appended was reported in history by a different provider. Description: (mM62hN) Medicare Co-Surgeon Rule - Modifier 62 – History Modifier 62 is present on the current claim, history claim has the same procedure code without the 62 modifier by a different provider. Resources: For additional guidance regarding billing for Co-Surgery/Team Surgery/Assistant Surgery Modifiers review:
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| Smart Edits Number: 434BN1 Message: Procedure code XXXXX required diagnosis code is missing. Description: Procedure code J0585, J0586, J0587 or J0588 missing a payable diagnosis code. Resources: Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). For additional guidance review: |
| Smart Edits Number: 434BN2 Message: Procedure code XXXXX required diagnosis code is missing. Description: Procedure code J0585, J0586, J0587 or J0588 missing a payable diagnosis code. Resources: Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). For additional guidance review: |
| Smart Edits Number: 436AN Message: Procedure code XXXXX requires an applicable POS and procedure code. Description: Procedure code XXXXX requires an applicable POS and procedure code. Resources: Visit the Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). For additional guidance review: |
| Smart Edits Number: mFR rule 17334 Message: Per Medicare guidelines, the frequency does not meet policy requirements for the procedure code. Description: Per Medicare guidelines, the frequency does not meet policy requirements for the procedure code. Resources: An ultrasound screening for AAA is a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of HHS, though the national coverage redetermination process) provided for the early detection of abdominal aortic aneurysms and includes a physician’s interpretation of the results. Ultrasound screening for AAA is a one-time benefit for all Medicare beneficiaries with certain risk factors for AAA. For additional guidance review:
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| Smart Edits Number: mFOMN Message: Per Medicare guidelines, it is inappropriate to report modifier XX for a procedure that is discontinued on a professional claim. This modifier is used by the facility to indicate that a procedure was terminated. Description: Per Medicare guidelines, it is inappropriate to report modifier XX for a procedure that is discontinued on a professional claim. This modifier is used by the facility to indicate that a procedure was terminated. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance, but has not changed in its definition or code. For additional guidance review: |
| Smart Edits Number: COVN3 Message: Procedure code K1034 is noncovered after DOS 5/11/2023. Description: Per CMS guidelines, procedure code K1034 is noncovered after DOS 5/11/2023. Resources: Beginning 4/4/2022 through the end of the COVID-19 PHE, Medicare covers and pays for OTC COVID-19 tests at no cost to people with Medicare Part B. This benefit has been added as a demonstration by CMS. The goal of the demonstration is to find out if Medicare payment for OTC COVID-19 tests will improve access to testing and result in Medicare savings or other program improvements. This demonstration will end when the PHE ends on 5/11/2023. For additional guidance on the OTC demonstration and the end of the PHE review: |
| Smart Edits Number: COVN2 Message: Coverage changes for COVID-19 testing. Medicare beneficiaries enrolled in Part B will continue to have coverage for provider ordered laboratory-conducted COVID-19 tests; however, current access to free OTC COVID-19 tests will end after DOS 5/11/2023. Description: Per CMS guidelines, the PHE will end 5/11/2023 Resources: Beginning 4/4/2022 through the end of the COVID-19 PHE, Medicare covers and pays for OTC COVID-19 tests at no cost to people with Medicare Part B. This benefit has been added as a demonstration by CMS. The goal of the demonstration is to find out if Medicare payment for OTC COVID-19 tests will improve access to testing and result in Medicare savings or other program improvements. This demonstration will end when the PHE ends on 5/11/2023. For additional guidance on the OTC demonstration and the end of the PHE review: |
| Smart Edits Number: PVN1N Message: This is a reminder that your Medicare enrollment record is due for revalidation. Failure to respond may result in a hold on payments and possible deactivation. Please disregard if you have started the revalidation process. Description: Per CMS, providers are required to revalidate periodically. Resources: Section 6401(a) of the Affordable Care Act requires that all enrolled providers or suppliers revalidate their Medicare enrollment information under new enrollment screening criteria. To maintain Medicare billing privileges, a Part B provider or supplier must resubmit and recertify the accuracy of its enrollment information every five years. If you are not sure when your revalidation is due access the Medicare Revalidation List tool or the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to obtain your revalidation due date. PECOS is also the fastest and most efficient way to submit your revalidation electronically; which allows providers to:
Additional resources and education to familiarize yourself with enrollment revalidation are available. |
| Smart Edits Number: 012fN4 Message: Required modifier missing for procedure code XXXXX when billed with diagnosis code XXXXX. S/B Procedure code XXXXX billed is missing an appropriate modifier and diagnosis code. Description: (012fN4) Cardiac Pacemakers missing KX Modifier S/B. (012fN4) Cardiac Pacemakers missing SC and KX modifiers without payable diagnosis.
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: p55N Message: When modifier XX is submitted the beginning and ending date of service should equal the date of surgery. Description: This edit will be generated for services that are subject to multiple surgery pricing and there is a date range on the detail with a quantity billed greater than one. Resources: The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators. For additional guidance review: |
| Smart Edits Number: 176BN2 Message: HCPCs 82306 required diagnosis is missing. Description: An eligible diagnosis for procedure code 82306 is not reported. Resources: Visit our Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 926BN1 Message: The submitted Procedure code 92132 must be billed with both a required diagnosis code and applicable diagnosis code pointer. Description: This edit will be generated for Scanning Computerized Ophthalmic Diagnostic Imagining services when the diagnosis reported is not eligible according to the corresponding LCD. Resources: Visit our Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 926BN2 Message: The submitted procedure code 92133 must be billed with both a required diagnosis code and diagnosis code pointer. Description: This edit will be generated for Scanning Computerized Ophthalmic Diagnostic Imagining services when the diagnosis reported is not eligible according to the corresponding LCD. Could include dates of service on or after 10/15/2019 and less than or equal to 9/30/2022 needs a required diagnosis code and diagnosis pointer. Resources: Visit our Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 926BN3 Message: The submitted procedure code 92133 must be billed with both a required diagnosis code and diagnosis code pointer. Description: This edit will be generated for Scanning Computerized Ophthalmic Diagnostic Imagining services when the diagnosis reported is not eligible according to the corresponding LCD. Could include dates of service on or after 10/1/2022 needs a required diagnosis code and diagnosis pointer. Resources: Visit our Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: 926BN4 Message: The submitted procedure code 92134 must be billed with both a required diagnosis code and diagnosis code pointer. Description: This edit will be generated for Scanning Computerized Ophthalmic Diagnostic Imagining services when the diagnosis reported is not eligible according to the corresponding LCD. Resources: Visit our Medical Policy section of our website for LCDs, related billing and coding articles and additional medical policy topics. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. For additional guidance review: |
| Smart Edits Number: mB2N Message: Per Medicare Guidelines, the usual payment adjustment for bilateral procedures does not apply. Base payment for each side of the actual charge for each side or 100% of the fee schedule amount for each side. Description: The modifier billed is invalid. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance, but has not changed in its definition or code. Bilateral indicator of 1 must be reported with 1 unit of service and modifier 50. The 50 modifier identifies the service as being performed on both sides of the body. Do not report anatomical modifiers in addition to modifier 50.
Note: NGS requires placement of pricing modifiers in the first modifier position to correctly price and process claims. Also, when submitting modifiers ensure there are no blanks in between the modifier fields. The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators. For additional guidance review: |
| Smart Edits Number: COVN Message: Procedure code XXXXX has been reached for the calendar month. Description: (COVN) NGS COVID OTC Test Kit Limit Rule
For example, if the beneficiary receives eight over-the-counter COVID-19 tests on 4/14/2022 through this initiative, they will not be eligible for another round of eight free over-the-counter COVID-19 tests until 5/1/2022. Note: there can be multiple tests per box, so eight tests may come in fewer than eight boxes. Please use the following resources to obtain further information about the COVID-19 OTC demonstration.
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| Smart Edits Number: mIVA Message: Per Medicare guidelines, administration code XXXXX billed for vaccine code XXXXX on a history claim is not appropriate. Description: (mIVA) Per Medicare guidelines, administration code XXXXX billed for vaccine code XXXXX on a history claim is not appropriate. Resources: Please review and use the appropriate flu vaccine code located on the CMS Seasonal Influenza Vaccines Pricing web page to avoid processing delays and claim denials. Pricing information for the G0008 administration code is located on the Vaccines and Administration Pricing section on the Fee Schedule Lookup web page. For additional guidance please visit the CMS’ Flu Shot web page. |
| Smart Edits Number: 057N1 Message: Procedure code XXXXX requires an appropriate modifier. Description: (057N1) Procedure code requires modifiers LT, RT or 50
Bilateral indicator of 1 must be reported with 1 unit of service and modifier 50. The 50 modifier identifies the service as being performed on both sides of the body. Do not report anatomical modifiers in addition to modifier 50.
Note: NGS requires placement of pricing modifiers in the first modifier position to correctly price and process claims. Also, when submitting modifiers ensure there are no blanks in between the modifier fields. For additional guidance with modifiers visit: Modifiers Used in CMS-1500 Claim Reporting General Modifier Information. |
| Smart Edits Number: 057N2 Message: Procedure code XXXXX requires an appropriate modifier. Description: (057N2) Procedure code requires modifier LT or RT
Side of body modifiers are anatomical specific modifiers to designate the area or part of the body which the procedure was performed. Note: NGS requires placement of pricing modifiers in the first modifier position to correctly price and process claims. Also, when submitting modifiers ensure there are no blanks in between the modifier fields. For additional guidance with modifiers visit: Modifiers Used in CMS-1500 Claim Reporting General Modifier Information. |
| Smart Edits Number: 057N3 Message: Procedure code XXXXX requires an appropriate modifier. Description: (057N3) Procedure code requires modifiers LC, LD, LM, RC, OR, RI
Coronary artery modifiers are anatomical specific modifiers used to identify the coronary artery. Note: NGS requires placement of pricing modifiers in the first modifier position to correctly price and process claims. Also, when submitting modifiers ensure there are no blanks in between the modifier fields. For additional guidance with modifiers visit: Modifiers Used in CMS-1500 Claim Reporting General Modifier Information. |
| Smart Edits Number: pCQN Message: The submitted modifier for a physical therapist assistant requires the outpatient physical therapy plan of care modifier. Description: (pCQ) Plan of Care Modifier is Missing.
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For additional guidance visit: |
| Smart Edits Number: ESR2N Message: It is inappropriate to submit an ESRD related service code (2-3 face-to-face visits based on patient's age) more than once per month. Description: (ESR2N) Maximum Frequency ESRD Related Services 2-3 face-to-face visits based on patient's age
The term ‘month’ means a calendar month. The first month in which the beneficiary begins dialysis treatment marks the beginning of treatments through the end of the calendar month. Thereafter, the term ‘month’ refers to a calendar month.
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| Smart Edits Number: ESR3N Message: It is inappropriate to submit an ESRD related service code (2-3 face-to-face visits based on patient's age) more than once per month. Description: (ESR3N) Maximum Frequency ESRD Related Services 2-3 face-to-face visits based on patient's age.
The term ‘month’ means a calendar month. The first month in which the beneficiary begins dialysis treatment marks the beginning of treatments through the end of the calendar month. Thereafter, the term ‘month’ refers to a calendar month.
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| Smart Edits Number: mHCS rule 30172 Message: Per Medicare guidelines, HCPCS code G0472 is not a covered service when submitted without ICD-10-CM code Z72.89 or F19.20 for a Medicare Beneficiary born prior to 1945 or after 1965. Description: (mHCS rule 30172) Medicare Hepatitis C Screening Services
For additional guidance visit: |
| Smart Edits Number: CCM2 Message: CCM service procedure code XXXXX is included in procedure code XXXXX reported on a history claim when reported in the same calendar month. Description: (CCM2) CCM in other service during same month
NCCI includes two types of edits:
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| Smart Edits Number: CCM2h Message: Chronic care management (CCM) service procedure code XXXXX is included in procedure code XXXXX reported on a history claim when reported in the same calendar month. Description: (CCM2h) CCM found in history included in other services during the same month
NCCI includes two types of edits:
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| Smart Edits Number: ASDN Message: An anesthesia service with an equal or higher base unit value than XXXXX was billed on MM/DD/YYYY. Only the anesthesia code with the higher base unit value should be billed per operative session. Description: (ASDN) Anesthesia Secondary Procedure
On the CMS-1500 claim form, report the anesthesia procedure code with the highest base unit value in Item 24D. In Item 24G, indicate the total time for all the procedures performed. For additional anesthesia billing and coding information please visit our Anesthesia Billing Guide. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For a listing of the claim field requirements please visit: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12 Section 50. |
| Smart Edits Number: f17N Message: The HCPCS code is inconsistent with the modifier used as the patient was pronounced deceased after the ambulance was called. Description: (f17N) Ambulance Services Submitted with Modifier QL
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For a listing of the claim field requirements please visit: CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, “Ambulance Services”. Additional ambulance billing and coding information can be found within our Ambulance Billing Guide. |
| Smart Edits Number: f27N Message: Records indicate the patient has received care by Provider XXX within the last three years. Please review to see if an established patient code is more suitable. XXXXX was billed for date of service XX/XX/XXXX. Description: (f27N) New Patient Code Billed for an Established Patient
Example: If a professional component of a previous procedure is billed in a three-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an X-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For a listing of the claim field requirements please visit: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7. Additional new patient vs. established patient information can be found in our New vs. Established Patients FAQs and our related article: Definition of New Patient for Billing Evaluation and Management Services. |
| Smart Edits Number: f30N Message: Procedure Code XXXXX should not be submitted with Modifier 59, XE, XP, XS or XU.
The f30N edit will set when a code/modifier combination is not valid. Resources: To distinguish the proper use of these modifiers please visit: MLN® Fact Sheet: Proper Use of Modifiers 59 & -X{EPSU} Additional billing and usage guidelines can be found in our Modifier Job Aid under Modifier 59 and the Subset Modifiers XE, XP, XS, XU – Specific Modifiers for Distinct Procedural Services. |
| Smart Edits Number: mDP Message: Procedure Code XXXXX is within the global period of XX days of History Procedure Code YYYYY performed on mm/dd/yyyy by the same provider. The diagnosis indicates it is not for the same condition. Please review to determine if a modifier is appropriate. Description: (mDP) Medicare Post-Op Unrelated Service by Provider
This policy helps prevent Medicare payments for services that are more or less comprehensive than intended. In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, cosurgeons, and team surgeons. The information that follows describes the components of a global surgical package and billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians. The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. More information regarding the components of a global surgery package including the billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians please visit: MLN® Booklet: Global Surgery. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For a listing of the claim field requirements please visit: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.6.6, 40.1, 40.2. Additional information and billing guidance can be found in our article Global Surgery. |
| Smart Edits Number: mFP Message: Procedure Code XXXXX is within the global period of procedure code YYYYY. The diagnosis indicates it is for the same condition. Please review to determine if a modifier is appropriate. Description: (mFP) Medicare Global Follow-Up by Provider
This policy helps prevent Medicare payments for services that are more or less comprehensive than intended. In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, cosurgeons, and team surgeons. The information that follows describes the components of a global surgical package and billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians. The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. More information regarding the components of a global surgery package including the billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians please visit: MLN® Booklet: Global Surgery. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For a listing of the claim field requirements please visit: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.6.6, 40.1, 40.2. Additional information and billing guidance can be found in our article Global Surgery. |
| Smart Edits Number: mMUE Rule 33799 Message: Per Medicare's Medically Unlikely Edits, the units of service billed for procedure code XXXXX exceed the allowed units of frequency policy. Description: (mMUE 33799) Medicare Practitioner Medically Unlikely Edits
To learn more about MUE guidelines, editing and billing/reporting visit: |
| Smart Edits Number: mPDP Message: The PD modifier must be billed with the 26 modifier. Description: (mPDP) Modifier PD when Modifier 26 is missing
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| Smart Edits Number: mUH Message: Per Medicare CCI guidelines, history procedure code X has an unbundle relationship with procedure code X Description: (mUH) Medicare CCI Unbundle
Please visit: |
| Smart Edits Number: mFR Rule 30005 Message: Per Medicare guidelines, the frequency does not meet policy requirements for the procedure code. Description: (mFR 30005) Hepatitis C Virus Screening Frequency
Additional billing and guidance can be found in our Preventive Services Guide. |
| Smart Edits Number: mFR Rule 30243 Message: Per Medicare guidelines, the frequency does not meet policy requirements for the procedure code. Description: (mFR 30243) Kidney Disease Education Service Frequency Rule
Contractors shall pay for kidney disease education (KDE) services that meet the specific conditions including no more than six sessions of KDE services are provided in a lifetime. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For a listing of the claim field requirements please visit: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 20 |
| Smart Edits Number: mFR Rule 30246 Message: Per Medicare guidelines, the frequency does not meet policy requirements for the procedure code. Description: (mFR 30246) Medicare Lung Cancer Screening Service Frequency Rule
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. For a listing of the claim field requirements please visit: CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 210.14 and CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 220. Additional billing and guidance can be found in our Preventive Services Guide. |
| Smart Edits Number: BAG Message: Per LCD or NCD guidelines, procedure code XXXXX has not met the associated age relationship criteria for CMS ID(s) XXXX. Description: (BAG) LCD Part B Procedure Not Typical with Patient Age
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit: CMS Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1. |
| Smart Edits Number: BPO Message: Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Place of Service relationship criteria for CMS ID(s) XXXXX. Description: (BPO) LCD Part B Invalid Place of Service
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). NCDs are made through an evidence-based process, with opportunities for public participation. Visit: CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services and CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services. |
| Smart Edits Number: mAS Message: Medicare statutory payment restriction for assistants at surgery applies to the procedure XXXXX. Description: (mAS) Medicare No Payment for Assistant Surgeons
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| Smart Edits Number: mCO Message: Billing for co-surgeons is not permitted for the procedure XXXXX. Description: (mCO) Medicare Co-Surgeons Not Permitted
The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such as co-surgery, team surgery and assistant surgery. |
| Smart Edits Number: mGT Message: Per the Medicare Physician Fee Schedule, Procedure XXXXX describes the global code of a service or diagnostic test. Use of modifier XX is inappropriate for this procedure code. Description: (mGT) Medicare Global Test Only
The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such as PC/TC indicator which describes physician services that have global concept, professional or technical components. These include diagnostic and therapeutic radiology services, certain diagnostic tests that involve a physician’s interpretation and physician pathology services. |
| Smart Edits Number: mPC Message: Per the Medicare Physician Fee Schedule, Procedure XXXXX describes the physician work portion of a diagnostic test. Modifier XX is not appropriate. Description: (mPC) Professional Component Only
The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such as PC/TC indicator which describes physician services that have global concept, professional or technical components. These include diagnostic and therapeutic radiology services, certain diagnostic tests that involve a physician’s interpretation and physician pathology services. |
| Smart Edits Number: mTC Message: Per the Medicare Physician Fee Schedule, Procedure XXXXX describes only the technical portion of a service or diagnostic test. Modifier XX is not appropriate. Description: (mTC) Medicare Technical Component Only
The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such as PC/TC indicator which describes physician services that have global concept, professional or technical components. These include diagnostic and therapeutic radiology services, certain diagnostic tests that involve a physician’s interpretation and physician pathology services. |
| Smart Edits Number: mTS Message: Team Surgery is not permitted for Procedure XXXXX. Description: (mTS) Medicare Team Surgeons Not Permitted
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners, Section 40.8. |
| Smart Edits Number: mEV Message: The E/M code XXXXX on this claim line is billed in addition to another E/M code. The billing provider should bill one E/M code per patient per day. Please review for payment accuracy. Description: (mEV) Multiple Different E/M Codes on Same Day for Same Rendering Provider
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners, Section 30.6. |
| Smart Edits Number: mPI Message: Per the Medicare Physician Fee Schedule, Procedure Code XXXXX describes a physician interpretation for this service and is inappropriate in POS XX. Description: (mPI) Medicare Physician Interpretation
The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such as PC/TC indicator which describes physician services that have global concept, professional or technical components. These include diagnostic and therapeutic radiology services, certain diagnostic tests that involve a physician’s interpretation and physician pathology services. |
| Smart Edits Number: mPS Message: Per the Medicare Physician Fee Schedule, the PC/TC concept does not apply to Procedure XXXXX. Use of modifier XX is inappropriate. Description: (mPS) Medicare Physician Service Code
The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such as PC/TC indicator which describes physician services that have global concept, professional or technical components. These include diagnostic and therapeutic radiology services, certain diagnostic tests that involve a physician’s interpretation and physician pathology services. |
| Smart Edits Number: CAG Message: Procedure code XXXXX is not typical for a patient whose age is XX. The typical age range for this procedure is YY -XX. Description: (CAG) Procedure Not Typical with Patient Age.
The AMA is your trusted source for official CPT. The most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. To help you improve your understanding of CPT codes and coding issues, the AMA offers a variety of products and services that provide guidance and practical advice you can apply in your day-to-day practice. You can also view the coverage criteria for age restrictions for example:
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| Smart Edits Number: mAM Message: Per Medicare guidelines, HCPCS code XXXXX is identified as an ambulance code and requires an ambulance modifier appended. Description: (mAM) Medicare Ambulance Modifiers
Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Visit: Modifiers Used in CMS-1500 Claim Reporting General Modifier Information. |
| Smart Edits Number: mANM Message: Anesthesia code on this line requires an appropriate modifier. Description: (mANM) Medicare Anesthesia Modifiers
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| Smart Edits Number: mUN Message: Per CCI, procedure code XXXXX has an unbundle relationship with procedure code YYYYY billed for the same date of service. Description: (mUN) Unbundled Procedure (as per Medicare) on Separate Claim -- (History Edit)
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| Smart Edits Number: IMC Message: Modifier XX is invalid with XX and cannot be submitted on the same claim line. Description: IMC (Inappropriate Modifier Combination)
NGS requires placement of pricing modifiers in the first modifier position to process your claims correctly. When submitting modifiers also ensure there are no blanks in between the modifier fields. Visit: Modifiers Used in CMS-1500 Claim Reporting General Modifier Information |
| Smart Edits Number: mEVN Message: The E/M code XXXXX was performed on the same day of procedure code XXXXX performed by the same provider. The diagnosis indicates it is for the same condition. Description: (mEVN) Multiple Different E/M Codes on Same Day for Same Rendering Provider
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| Smart Edits Number: mSP Rule 8632 Message: Per Medicare guidelines procedure code XXXXX is within the global period of history procedure code YYYYY performed on mm/dd/yyyy by the same provider. Review documentation to determine if a modifier is appropriate. Description: (mSP) Medicare Post-Op Surgery By Provider.
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| Smart Edits Number: mEM Rule 8296 Message:
The mEM edit identifies claim lines where an E/M code is billed without modifier 25 on the same DOS as a minor surgical procedure, or billed without modifier 57 on the same DOS or one day before a major surgical procedure. Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, 40.1, 40.2.
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| Smart Edits Number: mEM Rule 8300 Message: Per Medicare guidelines, E/M code Current adjusted procedure code should not be billed without an appropriate modifier, on the same day of a minor procedure, or the same day or day before a major procedure, found on a history claim. Description: (mEM) Medicare 99291 or 99292 with no modifiers for critical care codes on the same DOS as a minor surgical procedure or one day before a major surgical procedure. Resources: CMS defines critical care as “the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient” and also defines a critical illness or injury as one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” In the final segments of this article, we have included several examples of critical care situations, provided by CMS. Visit: Critical Care Services: CPT Codes 99291-99292 |
| Smart Edits Number: mIM Rule 3474 Message: A Co Surgeon Modifier 62 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule. Description: (mIM) Medicare Inappropriate Modifier
Co-Surgery/Team Surgery/Assistant Surgery Modifiers. The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such as co-surgery, team surgery and assistant surgery. |
| Smart Edits Number: mIM Rule 26410 Message:
The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such PC/TC. |
| Smart Edits Number: mIM Rule 26413 Message: A Team Surgeon Modifier 66 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule Description: (mIM) Medicare Inappropriate Modifier
Co-Surgery/Team Surgery/Assistant Surgery Modifiers. The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such PC/TC. |
| Smart Edits Number: mIM Rule 26414 Message:
Co-Surgery/Team Surgery/Assistant Surgery Modifiers. The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such PC/TC. |
| Smart Edits Number: mIN Message: Medicare considers Procedure Code XXXXX as a bundled service when other payable services YYYYY are billed on the same day by the same provider and department. Description: (mIN) Medicare Injection Service
The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such PC/TC. |
| Smart Edits Number: mMOD Message: Per Medicare, use of modifier XX is not typical for procedure XXXXX. Description: (mMOD) Medicare Modifier Code Not Typical for Procedure Code
Anesthesia Modifiers - Use Anesthesia Modifiers Appropriately. |
| Smart Edits Number: mNP Message: Procedure Code XXXXX does not typically require performance by a physician in Place of Service XX, per Medicare Guidelines Description: (mNP) Medicare Non-Physician Service
The following is the current national POS code set, with facility and nonfacility designations noted for Medicare payment for services on the physician fee schedule: Medicare Part B 101 Manual - Appendix 3: Place of Service Codes. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5. The Fee Schedule Lookup tool is designed to take you through the selection steps prior to the display of pricing information based on the type of fee schedule selected. The tool assists in the search for pricing information, various payment policy indicators, RVUs and GPCIs by a specific fee code or the full fee schedule. The Description of Medicare Physician Fee Schedule Database Policy Indicators assists with providing the definitions of the various payment policy indicators such PC/TC. |
| Smart Edits Number: POS Message: Procedure Code XXXXX is not typically performed by a physician at Place of Service XX. Description: POS Not Typical with Procedure
The following is the current national POS code set, with facility and nonfacility designations noted for Medicare payment for services on the physician fee schedule: Medicare Part B 101 Manual - Appendix 3: Place of Service Codes. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5. |
| Smart Edits Number: mUO Message: Per CCI, Procedure Code ' XXXXX ' has an unbundle relationship with Procedure Code ' XXXXX ' billed for the same date of service. Review documentation to determine if a modifier override is appropriate. Description: (mUO) Unbundled Procedure (as per Medicare) on Current Line, Possible Modifier Override
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| Smart Edits Number: 008POVP Message: (008POVP) This claim line contains Modifier 56 and should be reviewed to determine if the service was paid at a reduced rate. Description: Adjusted modifier of 56. Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Please visit: CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40-40.3. |
| Smart Edits Number: mDT Message: Per the Medicare Physician Fee Schedule, Procedure Code XXXXX describes a diagnostic procedure that requires a professional component modifier in this POS XX. Description: (mDT) Medicare Diagnostic Testing in a Hospital Setting The mDT edit identifies claim lines which have procedure codes that are diagnostic tests performed in an inpatient or outpatient hospital or skilled nursing setting. When a provider is billing these services in an inpatient or outpatient hospital or skilled nursing setting, only the professional component should be billed (modifier 26). Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Please visit: CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40-40.3. Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Please visit: Modifiers Used in CMS-1500 Claim Reporting General Modifier Information. |
| Smart Edits Number: DTU Message: Discrepancy detected between the number of units XXXXX on this claim line and the difference between the Beginning DOS mm/dd/yyyy and the Ending DOS mm/dd/yyyy which is XX days. Description: (DTU) Date of Service to Units Discrepancy
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| Smart Edits Number: LPR Rule 4527 Message: Repeat lab procedure XXXXX may require a repeat modifier. Description: (LPR) Repeat Lab Procedure
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| Smart Edits Number: LPR Rule 4528 Message: Repeat lab procedure XXXXX may require a repeat modifier. The same lab procedure was performed by the same provider on the same day. Description: Repeat lab procedure XXXXX may require a repeat modifier. The same lab procedure code was performed by the same provider on the same day. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Visit: |
| Smart Edits Number: LPR Rule 4529 Message: Repeat lab procedure XXXXX may require a repeat modifier. The same lab procedure was performed by the same provider on the same day. Description: Repeat lab procedure XXXXX may require a repeat modifier. The same lab procedure code was performed by the same provider on the same day. Resources: Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Visit: |
| Smart Edits Number: mAWF Message: Per Medicare, this service is covered once in a lifetime. Description: (mAWF) Medicare once in a lifetime.
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
| Smart Edits Number: mAWP Message: Service occurred within a year of an initial preventive physical exam. Description: (mAWP) Medicare Annual Wellness Visit within a Previous Initial Preventive Physical Examination.
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
| Smart Edits Number: mAWS Message: Service occurred within a year of last covered annual wellness visit. Description: (mAWS) Medicare Annual Wellness Visit within a Previous Annual Wellness Visit.
The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
| Smart Edits Number: mMUE Rule 17678 Message: Per Medicare's Medically Unlikely Edits, the units of service billed for procedure code XXXXX exceed the allowed units. Description: (mMUE) Medicare Medically Unlikely Edits.
To learn more about MUE guidelines, editing and billing/reporting visit: |
| Smart Edits Number: mMUE Rule 17680 Message: Per Medicare's Medically Unlikely Edits, the units of service billed for procedure code XXXXX exceed the allowed units of frequency policy. Description: Per Medicare's Medically Unlikely Edits, the units of service billed for procedure code XXXXX exceed the allowed units of frequency policy. Resources: MUEs were developed by CMS in January 2007, as part of the effort to reduce the paid claims error rate for Medicare claims. These edits were developed with clinical input from both CMS and the MACs, and were set to define the maximum UOS that a provider would reasonably report for a single beneficiary on a single date of service. To learn more about MUE guidelines, editing and billing/reporting visit: |
| Smart Edits Number: NPT Message: This patient received care by provider XXXX within the last three years. An established patient E/M code should be used. Procedure code XXXXX was billed on XX/XX/XXXX. Description: New Patient Code Billed for Established Patient Claim History.
For additional billing guidelines for a new patient visit: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
| Smart Edits Number: FCRP Message: (FCRP) Procedure code Current adjusted procedure code found on this claim is a facility service code. This service is not to be reported on a professional claim. Description: Procedure codes of G0260, G0378, G0379, G0380, G0381, G0382, G0383, G0384 and G0463. Resources: Medicare Part A codes may not be paid by Medicare Part B. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
| Smart Edits Number: CPO Message: Only one individual may report a single care plan oversight CPT code per patient in the same month. Description: (CPO) Care Plan Oversight is allowed to be billed by only one individual and may be reported with a single CPT code per patient in the same month. Resources: Care plan oversight (CPO) exists where there is physician supervision of patients under care of hospices that require complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans. Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient’s care with the hospice during the month for which CPO services were billed. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
| Smart Edits Number: mMSP Message: Per Medicare guidelines the diagnosis code(s) billed does not support the medical necessity of G0101. Description: Per Medicare guidelines the diagnosis code(s) billed does not support the medical necessity of a screening pelvic exam. Resources: A screening pelvic exam is a type of gynecologic examination for women. Some of the conditions that health care providers look for during a pelvic examination include infections, fibroids, cervical polyps and ovarian cysts. Visit our Preventive Services Guide Preventive Services Guide - Screening Pelvic Examination and the MLN® Educational Tool: Medicare Preventative Services for billing and coverage criteria. The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
| Smart Edits Number: mPDT Message: The PD modifier may not be billed with the TC modifier. Description: The PD modifier may not be billed with the TC modifier. Resources: The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public. Visit: |
Revised 3/25/2024
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Form(s) you'll need:
Helpful Resources
EDI Front End Rejection Code Lookup Tool
Reset My EDI Password
Contact the EDI Help Desk
888-379-9132
Available by phone or email Monday–Friday*
8:00 a.m.–5:00 p.m. ET
8:00 a.m.–4:00 p.m. CT
* Closed for training on the 2nd and 4th Friday of the month.
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