Medicare Code Editor
The Medicare Code Editor (MCE) is a front-end software program that edits claims to
detect incorrect billing data. The MCE addresses three basic types of edits which will
support the DRG assignment. They include correct diagnosis and procedure coding,
coverage, and clinical edits.
Built into the MCE, which is the first portion of the Grouper program, are edits which
reject incomplete or impossible codes. Claims submitted with valid diagnoses and valid
diagnoses-surgical procedure combinations but are incorrect in that they do not represent
the actual diagnosis or procedure, cannot be detected. The responsibility for accuracy
rests with the hospital. However, a post claim approval review may be conducted by the
A/B MACs (A), using medical records and the approved claim.
Grouper Program
The Grouper program determines the DRG from data elements the hospital reported. It is
used on all inpatient discharge/transfer bills received from both PPS and non-PPS
facilities, including those from waiver States, long-term care hospitals, and excluded units.
Pricer Program
The Pricer program determines the amount to pay under prospective payment.
The Pricer program applies the DRG relative weights, hospital urban or rural and census
division location, hospital specific data, and beneficiary hospital data from the bill to
determine the amount payable for each PPS discharge bill.
Most hospitals should not need a Pricer program because only one rate per DRG applies
unless the claim results in a cost outlier for a beneficiary who's benefits are exhausted
during the stay. For those claims, the provider must identify the outlier threshold to
properly bill covered days on an inpatient claim. See §20.7.4 below. Hospitals and
hospital claims in multiple geographic areas may obtain a Pricer from
National Technical Institute
U.S. Department of Commerce
NTIS
Springfield,
VA 22161.
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