Encounter Data System - CSSC Operations

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10.0 Encounter Data Institutional Processing and Pricing System EditsAfter an Institutional encounter passes translator and CEM level editing and an ICN is received on a277CA, the Encounter Data Front-End System (EDFES) then transfers the encounter to the EncounterData Institutional Processing and Pricing System (EDIPPS), where editing, processing, pricing, andstorage occurs. In order to assist MAOs and other entities in submission of encounter data through theEDIPPS, the current list of the EDIPPS edits is provided in Table 11 below.The EDIPPS edits are organized in nine (9) different categories, as provided in Table 11, Column 2. TheEDIPPS edit categories include the following:ValidationProviderBeneficiaryReferenceLimitConflictPricingDuplicateNCCIThere are two (2) edit dispositions: Informational and Reject, which are provided in Column 3 of Table11 below. Informational edits are being reviewed and further guidance will be provided in a futurerelease of the Companion Guide. Informational edits will cause an informational flag to be placed onthe encounter; however, the Informational edit will not cause processing and/or pricing to cease.Reject edits will cause an encounter to stop processing and/or pricing, and the MAO or other entitymust resubmit the encounter through the EDFES. The encounter must then pass translator and CEMlevel editing prior to the data being transferred to the EDIPPS for reprocessing. The EDIPPS editmessage, as provided in Column 4 in Table 11 below, will be provided on Encounter Data ProcessingSystem (EDPS) transaction reports to provide further information to the MAO or other entity of thespecific reason for the edit generated.If there is no reject edit at the header level and at least one of the lines is accepted, then the encounteris accepted. If there is no reject edit at the header level, but all lines are rejected, then the encounterwill be rejected. If there is a reject edit at the header level, the encounter will be rejected.Table 11 reflects only those edits that are currently programmed in the EDIPPS. MAOs and otherentities should note that as testing progresses, it may be determined that the current edits requiremodifications, additional edits may be necessary, or edits may be temporarily or permanentlydeactivated. MAOs and other entities must always reference the most recent version of the CompanionGuide to determine the current edits in the EDIPPS.837 Institutional Companion Guide Version 8.0/June 201250
TABLE 11 - ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITSEDIPPSEdit#EDIPPS EditCategoryEDIPPS EditDisposition837 Institutional Companion Guide Version 8.0/June 2012EDIPPS Edit Error Message00010 Validation Reject From Date Of Service Is Greater Than TCN Date00012 Validation Reject Date Of Service Is Less Than 01-01-201200025 Validation Reject To Date Of Service Is After Date Of Claim Receipt00265 Validation Reject Adjustment Or Void ICN Not Found In History00699 Validation Reject Void Submission Must Match Original EncounterUnable To Void Due To Different Billing Provider On Void00761 Validation Reject From Original01405 Provider Reject Sanctioned Provider01415 Provider Informational Rendering Provider Not Eligible For Date Of Service02106 Beneficiary Informational Invalid Beneficiary Last NameBeneficiary Health Insurance Carrier Number (HICN) Not02110 Beneficiary Reject On File02112 Beneficiary Reject Date Of Service Is After Beneficiary Date Of Death02120 Beneficiary Informational Beneficiary Gender Mismatch02125 Beneficiary Reject Beneficiary Date Of Birth MismatchBeneficiary Not Enrolled In Medicare Advantage02240 Beneficiary Reject Organization For Date Of Service02255 Beneficiary Reject Beneficiary Not Part A Eligible For Date Of Service02256 Beneficiary Reject Beneficiary Not Part C Eligible For Date Of Service03015 Reference Reject DOS Spans Procedure Code Effective/End DateInvalid Case Mix Group For Inpatient Rehabilitation03022 Pricing Reject Facility Claim03101 Reference Reject Invalid Gender For Procedure Code03102 Pricing Informational*Provider Type Or Specialty Not Allowed To Bill ForProcedure17085 Validation RejectInpatient/SNF Same Day Transfer Must Have ConditionCode 4017100 Validation Reject Type Of Bill - Home Health Claim Missing Date Of Service17110 Validation Reject TOB 74X Or 75X Requires HCPCS And Revenue Code17257 Validation Informational Revenue - Revenue Code 910 Not Allowed17285 Validation Reject Billed Lines Require Charges (Few Exceptions)17295 Conflict RejectInpatient Claim Missing Revenue Code or OutpatientClaim Missing Either Revenue Code or HCPCS Code17310 Validation RejectSurgical Revenue Code 036X Requires Surgical ProcedureCode17330 Reference Reject Adjustment Not Allowed for A RAP* temporarily informational and will be changed to reject upon further analysis51
Page 1 and 2: ___________________________________
Page 3 and 4: Table of Contents1.0 Introduction1.
Page 5 and 6: 1.0 Introduction1.1 ScopeThe CMS En
Page 7 and 8: 1.4 ReferencesMAOs and other entiti
Page 9 and 10: other entities should refrain from
Page 11 and 12: ISATABLE 1 - ISA-IEA INTERCHANGE EL
Page 13 and 14: TABLE 3 - ST-SE TRANSACTION SET HEA
Page 15 and 16: TABLE 4 - 837 INSTITUTIONAL HEALTH
Page 21 and 22: The 277CA is used to acknowledge th
Page 23 and 24: TABLE 6 - TESTING FILE NAME COMPONE
Page 25 and 26: The report format example is as fol
Page 27 and 28: TABLE 10 - 837 INSTITUTIONAL PERMAN
Page 29 and 30: 9.0 837 Institutional Business Case
Page 31 and 32: SBR*P*18*XYZ1234567******16~AMT*D*2
Page 33 and 34: HI*BG:01~NM1*71*1*JONES*AMANDA*AL**
Page 35 and 36: HI*BR:3121:D8:20120330~HI*BH:41:D8:
Page 37 and 38: HI*BE:30:::20~HI*BG:01~NM1*71*1*JON
Page 39 and 40: HI*BE:30:::20~HI*BG:01~NM1*71*1*JOH
Page 41 and 42: N3*705 E HUGH ST~N4*NORFOLK*VA*2350
Page 43 and 44: SV2*0300*HC:D0999*50.00*UN*1~DTP*47
Page 45 and 46: N4*NORFOLK*VA*235049999~REF*T4*Y~LX
Page 47 and 48: N4*NORFOLK*VA*235099999~NM1*PR*2*HA
Page 49: SBR*P*18*XYZ1234567******16~AMT*D*9
Page 53 and 54: TABLE 11 - ENCOUNTER DATA INSTITUTI

Encounter Data System - CSSC Operations

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