Processing Requirements

9. Unacceptable Principal Diagnosis 

There are selected codes that describe a circumstance which influences an individual's health status but is not a current illness or injury; therefore, they are unacceptable as a principal diagnosis. For example, the diagnosis code for family history of a certain disease would be an unacceptable principal diagnosis since the patient may not have the disease. In a few cases, there are codes that are acceptable if a secondary diagnosis is coded. If no secondary diagnosis is present for them, MCE returns the message "requires secondary dx." The A/B MAC (A) may review claims with specific codes in the Unacceptable Principal Diagnosis section and a secondary diagnosis. A/B MACs (A) may choose to review as a principal diagnosis if data analysis deems it a priority. If these codes are identified without a secondary diagnosis, the A/B MAC (A) returns the bill to the hospital and requests a secondary diagnosis that describes the origin of the impairment. Also, bills containing other "unacceptable principal diagnosis" codes are returned. The hospital reviews the medical record and/or face sheet and enters the principal diagnosis that describes the illness or injury before returning the bill. 

10. Nonspecific O.R. Procedures 

Effective October 1, 2007 (FY 2008), the non-specific O.R. procedure edit was discontinued and will appear for claims processed using MCE version 2.0-23.0 only. 

11. Noncovered O.R. Procedures 

There are some O.R. procedures for which Medicare does not provide payment. The A/B MAC (A) will return the bill requesting that the non-covered procedure and its associated charges be removed from the covered claim, Type of Bill (TOB) 11X. If the hospital wishes to receive a Medicare denial, etc., the hospital may submit a non-covered claim, TOB 110, with the non-covered procedure/charges. 

12. Open Biopsy Check 

Biopsies can be performed as open (i.e., a body cavity is entered surgically), percutaneously, or endoscopically. The MS-DRG Grouper logic assign a patient to different MS-DRGs depending upon whether or not the biopsy was open. In general, for most organ systems, open biopsies are performed infrequently. 

Effective October 1, 1987, there are revised biopsy codes that distinguish between open and closed biopsies. To make sure that hospitals are using diagnosis codes correctly, the A/B MAC (A) requests O.R. reports on a sample of 10 percent of claims with open biopsy procedures for review on a post payment basis.

 If the O.R. report reveals that the biopsy was closed (performed percutaneously, endoscopically, etc.) the A/B MAC (A) changes the procedure code on the bill to the closed biopsy code and processes an adjustment bill. Some biopsy codes (3328 and 5634) have two related closed biopsy codes, one for closed endoscopic and for closed percutaneous biopsies. The A/B MAC (A) assigns the appropriate closed biopsy code after reviewing the medical information. 

Effective October 1, 2010, the open biopsy check edit was discontinued and was only used when processing MCE version 2.0 - 26.0. 

Effective with the implementation of ICD-10, ICD-10-PCS codes will be implemented which clearly identify in greater detail the approach used in the biopsy