5. Sex Conflict
The MCE detects inconsistencies between a patient's sex and a diagnosis or procedure on
the patient's record. Examples are:
• Male patient with cervical cancer (diagnosis).
• Male patient with a hysterectomy (procedure).
In both instances, the indicated diagnosis or the procedure conflicts with the stated sex of
the patient. Therefore, either the patient's diagnosis, procedure or sex is incorrect.
The MCE contains listings of male and female related diagnosis and procedure codes and
the corresponding English descriptions. The hospital should review the medical record
and/or face sheet and enter the proper sex, diagnosis, and procedure before returning the
bill.
6. Manifestation Code
As Principal Diagnosis
A manifestation code describes the manifestation of an underlying disease, not the disease
itself, and therefore, cannot be a principal diagnosis. The MCE contains listings of
diagnosis codes identified as manifestation codes. The hospital should review the medical
record and/or face sheet and enter the proper diagnosis before returning the bill.
7. Nonspecific Principal Diagnosis
Effective October 1, 2007 (FY 2008), the non-specific principal diagnosis edit was
discontinued and will appear for claims processed using MCE version 2.0-23.0 only.
8. Questionable Admission
There are some diagnoses which are not usually sufficient justification for admission to an
acute care hospital.
The MCE contains a listing of diagnosis codes identified as "Questionable Admission"
when used as principal diagnosis.
The A/B MACs (A) may review on a post-payment basis all questionable admission cases.
Where the A/B MAC (A) determines the denial rate is sufficiently high to warrant, it may
review the claim before payment.
