Risk Adjustment Data Submission

Collection of Risk Adjustment Data from MA Organizations, Section 1876 Cost HMOS/CMPS, Section 1833 HCPPS, MMPS, and PACE Organizations (CMS-10340)

12_2_9 Companion Guide - Institutional Transaction based on ASC X12 (rev OSORA PRA)

Risk Adjustment Data Submission

OMB: 0938-1152

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1152 can be found here:

Document [pdf]

Download: pdf | pdf

OMB Number: 0938-1152
Expiration Date: TBD

_________________________________________________________________

Encounter Data System

Standard Companion Guide Transaction Information
Instructions related to the 837 Health Care Claim: Institutional
Transaction based on ASC X12 Technical Report Type 3 (TR3), Version
005010X223A2
Companion Guide Version Number: 29.0
Created: May 2014

837 Institutional Companion Guide Version 29.0/May 2014

Preface
The Encounter Data System (EDS) Companion Guide contains information to assist Medicare Advantage
Organizations (MAOs) and other entities in the submission of encounter data. The EDS Companion
Guide is under development and the information in this version reflects current decisions and will be
modified on a regular basis. All of the EDS Companion Guides are identified with a version number,
which is located in the version control log on the last page of the document. Users should verify that
they are using the most current version.
Questions regarding the contents of the EDS Companion Guide should be directed to
[email protected].

837 Institutional Companion Guide Version 29.0/May 2014

Table of Contents
1.0

Introduction
1.1
Scope
1.2
Overview
1.3
Major Updates
1.3.1 EDS Acronyms
1.4
References

2.0

Contact Information
2.1
CSSC
2.2
Applicable Websites/Email Resources

3.0

File Submission
3.1
File Size Limitations
3.2
File Structure

4.0

Control segments/envelopes
4.1
ISA/IEA
4.2
GS/GE
4.3
ST/SE

5.0

Transaction Specific Information
5.1
837-I Transaction Specific Table

6.0

Acknowledgements and/or Reports
6.1
TA1
6.2
999
6.3
277CA
6.4
MAO-001 – Encounter Data Duplicates Report
6.5
MAO-002 – Encounter Data Processing Status Report
6.6
Reports File Naming Conventions
6.6.1 Testing
6.6.2 Production
6.7
EDFES Notifications

7.0

Front-End Edits
7.1
Deactivated Front-End Edits
7.2
Temporarily Deactivated Front-End Edits

8.0

Duplicate Logic
8.1
Header Level
8.2
Detail Level

Table of Contents
837 Institutional Companion Guide Version 29.0/May 2014

9.0

Institutional Business Cases
9.1
Standard Institutional Encounter
9.2
Capitated Institutional Encounter
9.3
Chart Review Institutional Encounter – No Linked ICN
9.4
Chart Review Institutional Encounter – Linked ICN
9.5
Complete Replacement Institutional Encounter
9.6
Complete Deletion Institutional Encounter
9.7
Atypical Provider Institutional Encounter
9.8
Paper Generated Institutional Encounter
9.9
True Coordination of Benefits Institutional Encounter
9.10 Bundled Institutional Encounter

10.0

Encounter Data Institutional Processing and Pricing System Edits
10.1 EDIPPS Enhancements Implementation Dates
10.2 EDPS Edits Prevention and Resolution Strategies
10.2.1 EDPS Edits Prevention and Resolution Strategies – Phase I
10.2.2 EDPS Edits Prevention and Resolution Strategies – Phase II
10.2.3 EDIPPS Edits Prevention and Resolution Strategies – Phase III

11.0

Submission of Default Data in a Limited Set of Circumstances
11.1 Default Data Reason Codes

12.0

Tier II Testing

13.0

EDS Acronyms

837 Institutional Companion Guide Version 29.0/May 2014

1.0

Introduction

1.1

Scope

The CMS Encounter Data System (EDS) 837-I Companion Guide addresses how MAOs and other entities
conduct Institutional claims Health Information Portability and Accountability Act (HIPAA) standard
electronic transactions with CMS. The CMS EDS supports transactions adopted under HIPAA, as well as
additional supporting transactions described in this guide.
The CMS EDS 837-I Companion Guide must be used in conjunction with the associated 837-I
Implementation Guide (TR3) and the Encounter Data Front-End System (EDFES) CEM Edits Spreadsheets.
The instructions in the 837-I CMS EDS Companion Guide are not intended for use as a stand-alone
requirements document.
1.2

Overview

The CMS EDS 837-I Companion Guide includes information required to initiate and maintain
communication exchange with CMS. The information is organized in the sections listed below:
•

Contact Information: Includes telephone numbers and email addresses for EDS contacts.

•

Control Segments/Envelopes: Contains information required to create the ISA/IEA, GS/GE, and
ST/SE control segments in order for transactions to be supported by the EDS.

•

Acknowledgements and Reports: Contains information for all transaction acknowledgements
and reports sent by the EDS.

•

Transaction Specific Information: Describes the details of the HIPAA X12 Implementation Guides
(IGs), using a tabular format. The tables contain a row for each segment with CMS and IG
specific information. That information may contain:
o Limits on the repeat of loops or segments
o Limits on the length of a simple data element
o Specifics on a sub-set of the IG’s internal code listings
o Clarification of the use of loops, segments, and composite or simple data elements
o Any other information tied directly to a loop, segment, and composite or simple data
element pertinent to trading electronically with CMS.

In addition to the row for each segment, one (1) or more additional rows are used to describe the EDS’
usage for composite or simple data elements and for any other information.
1.3

Major Updates

1.3.1

EDS Acronyms

MAOs and other entities may reference Section 13.0, Table 19 for additional acronyms frequently used
by the EDS.

837 Institutional Companion Guide Version 29.0/May 2014

1.4

References

MAOs and other entities must use the ASC X12N IG adopted under the HIPAA Administrative
Simplification Electronic Transaction rule, along with CMS’ Encounter Data Participant Guides and EDS
Companion Guides, for development of the EDS transactions. These documents are accessible on the
CSSC Operations website at www.csscoperations.com. Additionally, CMS publishes the EDS’ submitter
guidelines and application, testing documents, 837 EDS Companion Guides and Encounter Data
Participant Guides on the CSSC Operations website.
MAOs and other entities must use the most current national standard code lists applicable to the 5010
transaction. The code lists may is accessible at the Washington Publishing Company (WPC) website at:
http://www.wpc-edi.com.
The applicable code lists are as follows:
• Claim Adjustment Reason Code (CARC)
• Claim Status Category Codes (CSCC)
• Claim Status Codes (CSC)
CMS provides X12 5010 file format technical edit spreadsheets for the 837-I and 837-P. The edits
included in the spreadsheets are provided to clarify the WPC instructions or add Medicare specific
requirements. In order to determine the implementation date of the edits contained in the
spreadsheet, MAOs and other entities should initially refer to the spreadsheet version identifier. The
version identifier is comprised of ten (10) characters, as follows:
•
•
•

•

Positions 1-2 indicate the line of business:
o EA – Part A (837-I)
o EB – Part B (837-P)
Positions 3-6 indicate the year (e.g., 2011)
Position 7 indicates the release quarter month
o 1 – January release
o 2 – April release
o 3 – July release
o 4 – October release
Positions 8-10 indicate the spreadsheet version iteration number (e.g., V01-first iteration, V02second iteration)

The effective date of the spreadsheet is the first calendar day of the release quarter month. The
implementation date is the first business Monday of the release quarter month. Federal holidays that
potentially occur on the first business Monday are considered when determining the implementation
date. For example, the edits contained in a spreadsheet version of EA20131V01 are effective January 1,
2013 and implemented on January 7, 2013.
2.0

Contact Information

2.1

The Customer Service and Support Center (CSSC)

The Customer Service and Support Center (CSSC) personnel are available for questions from 8:00 AM –
7:00PM EST, Monday-Friday, with the exception of federal holidays. MAOs and other entities are able
to contact the CSSC by phone at 1-877-534-CSSC (2772) or by email at
[email protected].

837 Institutional Companion Guide Version 29.0/May 2014

2.2

Applicable Websites/Email Resources

The following websites provide information to assist in the EDS submission:
RESOURCE
EDPS Bulletin
EDS Inbox
EDS Participant Guides
EDS User Group Materials
ANSI ASC X12 TR3
Implementation Guides
Washington Publishing Company
Health Care Code Sets
CMS Edits Spreadsheet
3.0

File Submission

3.1

File Size Limitations

WEB ADDRESS
http://www.csscoperations.com/
[email protected]
http://www.csscoperations.com/
http://www.csscoperations.com/
http://www.wpc-edi.com/
http://www.wpc-edi.com/
http://www.cms.gov/MFFS5010D0/20_TechnicalDocumentation.asp

Due to system limitations, ISA/IEA transaction sets should not exceed 5,000 encounters, as the EDS
processes smaller files more efficiently than larger files.
In an effort to support and provide the most efficient processing system, and to allow for maximum
performance, CMS recommends that FTP submitters’ scripts upload no more than one (1) file per five (5)
minute intervals. Zipped files should contain one (1) file per transmission. NDM and Gentran/TIBCO
users may submit a maximum of 255 files per day.
3.2

File Structure – NDM/Connect Direct and Gentran/TIBCO Submitters Only

NDM/Connect Direct and Gentran/TIBCO submitters must format all submitted files in an 80-byte fixed
block format. This means MAOs and other entities must upload every line (record) in a file with a length
of 80 bytes/characters.
Submitters should create files with segments stacked, using only 80 characters per line. At position 81
of each segment, MAOs and other entities must create a new line. On the new line starting in position
1, continue for 80 characters, and repeat creating a new line in position 81 until the file is complete. If
the last line in the file does not fill to 80 characters, the submitter should space the line out to position
80 and then save the file.
Note: If MAOs and other entities are using a text editor to create the file, pressing the Enter key will
create a new line. If MAOs and other entities are using an automated system to create the file, create a
new line by using a CRLF (Carriage Return Line Feed) or a LF (Line Feed).
For example, the ISA record is 106 characters long:
The first line of the file will contain the first 80 characters of the ISA segment; the last 26 characters of
the ISA segment continue on the second line. The next segment will start in the 27th position and
continue until column 80.
ISA*00*
*00*
*ZZ*
ENH9999*ZZ*
4*^*00501*000000031*1*P*:~

80881*120816*114

837 Institutional Companion Guide Version 29.0/May 2014

Note to NDM/Connect:Direct Users: If a submitter has not established a sufficient number of
Generated Data Groups (GDGs) to accommodate the number of files returned from the EDFES, not all of
the EDFES Acknowledgement reports will be stored in the submitter’s system. To prevent this situation,
NDM/Connect:Direct submitters should establish a limit of 255 GDGs in their internal processing
systems.
4.0

Control Segments/Envelopes

4.1

ISA/IEA

The term interchange denotes the transmitted ISA/IEA envelope. Interchange control is achieved
through several “control” components, as defined in Table 1. The interchange control number is
contained in data element ISA13 of the ISA segment. The identical control number must also occur in
data element IEA02 of the IEA segment. MAOs and other entities must populate all elements in the
ISA/IEA interchange. There are several elements within the ISA/IEA interchange that must be populated
specifically for encounter data purposes. Table 1 below provides EDS Interchange Control (ISA/IEA)
specific elements.
Note: Table 1 presents only those elements that provide specific details relevant to encounter data.
When developing the encounter data system, users should base their logic on the highest level of
specificity. First, consult the WPC/TR3. Second, consult the CMS edits spreadsheets. Third, consult the
CMS EDS 837-I Companion Guide. If there are options expressed in the WPC/TR3 or the CEM edits
spreadsheet that are broader than the options identified in the CMS EDS 837-I Companion Guide, MAOs
and other entities must use the rules identified in the Companion Guide.
Legend
SHADED rows represent segments in the X12N Implementation Guide
NON-SHADED rows represent data elements in the X12N Implementation Guide
LOOP ID
ISA

REFERENCE
ISA01
ISA02
ISA03
ISA04
ISA05
ISA06
ISA08
ISA11
ISA13

TABLE 1 – ISA/IEA INTERCHANGE ELEMENTS
NAME
CODES
NOTES/COMMENTS
Interchange Control Header
Authorization Information
00
No authorization information present
Qualifier
Authorization Information
Use 10 blank spaces
Security Information Qualifier
00
No security information present
Security Information
Use 10 blank spaces
Interchange ID Qualifier
ZZ
CMS expects to see a value of “ZZ” to
designate that the code is mutually
defined
Interchange Sender ID
EN followed by Contract ID Number
Interchange Receiver ID
80881
Repetition Separator
^
Interchange Control Number
Must be fixed length with nine (9)
characters and match IEA02
Used to identify file level duplicate
collectively with GS06, ST02, and BHT03

837 Institutional Companion Guide Version 29.0/May 2014

LOOP ID
ISA

REFERENCE
ISA14
ISA15

IEA

IEA02
4.2

TABLE 1 – ISA/IEA INTERCHANGE ELEMENTS (CONTINUED)
NAME
CODES
NOTES/COMMENTS
Interchange Control Header
Acknowledgement Requested
1
A TA1 will be sent if the file is
syntactically incorrect, otherwise only a
‘999’ will be sent
Usage Indicator
T
Test
P
Production
Interchange Control Trailer
Interchange Control Number
Must match the value in ISA13

GS/GE

The functional group is outlined by the functional group header (GS segment) and the functional group
trailer (GE segment). The functional group header starts and identifies one or more related transaction
sets and provides a control number and application identification information. The functional group
trailer defines the end of the functional group of related transaction sets and provides a count of
contained transaction sets.
MAOs and other entities must populate all elements in the GS/GE functional group. There are several
elements within the GS/GE that must be populated specifically for encounter data collection. Table 2
provides EDS functional group (GS/GE) specific elements.
Note: Table 2 presents only those elements that require explanation.
LOOP ID
GS

REFERENCE
GS02
GS03
GS06
GS08

GE02
4.3

TABLE 2 - GS/GE FUNCTIONAL GROUP ELEMENTS
NAME
CODES
NOTES/COMMENTS
Functional Group Header
Application Sender’s Code
EN followed by Contract ID Number
This value must match the value in the
ISA06
Application Receiver’s Code
80881
This value must match the value in ISA08
Group Control Number
This value must match the value in GE02
Used to identify file level duplicates
collectively with ISA13, ST02, and BHT03
Version/Release/Industry
005010X223A2
Identifier Code
Functional Group Trailer
Group Control Number
This value must match the value in GS06

ST/SE

The transaction set (ST/SE) contains required, situational loops, unused loops, segments, and data
elements. The transaction set is outlined by the transaction set header (ST segment) and the
transaction set trailer (SE segment). The transaction set header identifies the start and identifies the
transaction set. The transaction set trailer identifies the end of the transaction set and provides a count
of the data segments, which includes the ST and SE segments. Several elements must be populated
specifically for encounter data purposes. Table 3 provides EDS transaction set (ST/SE) specific elements.
Note: Table 3 presents only those elements that require explanation.

837 Institutional Companion Guide Version 29.0/May 2014

LOOP ID
ST

TABLE 3 - ST/SE TRANSACTION SET HEADER AND TRAILER ELEMENTS
REFERENCE
NAME
CODES
NOTES/COMMENTS
Transaction Set Header
ST01
Transaction Set Identifier Code
837
ST02
Transaction Set Control
This value must match the value in SE02
Number
Used to identify file level duplicates
collectively with ISA13, GS06, and BHT03
ST03
Implementation Convention
005010X223A2
Reference
Transaction Set Trailer
SE01
Number of Included Segments
Must contain the actual number of
segments within the ST/SE
SE02
Transaction Set Control
This value must be match the value in
Number
ST02

5.0

Transaction Specific Information

5.1

837 Institutional: Data Element Table

Within the ST/SE transaction set, there are multiple loops, segments, and data elements that provide
billing provider, subscriber, and patient level information. MAOs and other entities should reference
www.wpc-edi.com to obtain the most current Implementation Guide. MAOs and other entities must
submit EDS transactions using the most current transaction version.
The 837 Institutional Data Element table identifies only those elements within the X12N Implementation
Guide that require comment within the context of the EDS’ submission. Table 4 identifies the 837
Institutional Implementation Guide by loop name, segment name, segment identifier, data element
name, and data element identifier for cross reference. Not all data elements listed in the table below
are required, but if they are used, the table reflects the values CMS expects to see.
LOOP ID

REFERENCE
BHT
BHT03

1000A

BHT06
NM1
NM102
NM109
PER
PER03
PER05

TABLE 4 - 837 INSTITUTIONAL HEALTH CARE CLAIM
NAME
CODES
NOTES/COMMENTS
Beginning of Hierarchical
Transaction
Originator Application
Must be a unique identifier across all files
Transaction Identifier
Used to identify file level duplicates collectively
with ISA13, GS06, and ST02.
Claim Identifier
CH
Chargeable
Submitter Name
Entity Type Qualifier
2
Non-Person Entity
Submitter Identifier
EN followed by Contract ID Number
Submitter EDI Contact
Information
Communication Number
TE
It is recommended that MAOs and other
Qualifier
entities populate the submitter’s telephone
number
Communication Number
EM
It is recommended that MAOs and other
Qualifier
entities populate the submitter’s email address

837 Institutional Companion Guide Version 29.0/May 2014

LOOP ID
1000A

REFERENCE
PER
PER07

1000B

NM1
NM102
NM103
NM109

2010AA

NM1
NM108
NM109

2010AA

N4
N403

2010AA

REF

SBR09
NM1
NM108

Subscriber Name
Subscriber Id Qualifier

NM109

Subscriber Primary Identifier

NM1
NM103
NM108

Payer Name
Payer Name
Payer ID Qualifier

NM109

Payer Identification

REF02

2010BA

2010BB

SBR
SBR01

Institutional provider default NPI when the
provider has not been assigned an NPI

Billing Provider City, State,
Zip Code
Zip Code

Billing Provider Tax
Identification Number
Reference Identification
Number
Billing Provider Tax
Identification Number
Subscriber Information
Payer Responsibility Number
Code
Claim Filing Indicator Code

REF01

2000B

TABLE 4 - 837 INSTITUTIONAL HEALTH CARE CLAIM (CONTINUED)
NAME
CODES
NOTES/COMMENTS
Submitter EDI Contact
Information
Communication Number
FX
It is recommended that MAOs and other
Qualifier
entities populate the submitter’s fax number
Receiver Name
Entity Type Qualifier
2
Non-Person Entity
Receiver Name
EDSCMS
Receiver ID
80881
Identifies CMS as the receiver of the
transaction and corresponds to the value in
ISA08 Interchange Receiver ID
Billing Provider Name
Billing Provider ID Qualifier
XX
NPI Identifier
Billing Provider Identifier
1999999976 Must be populated with a ten digit number,
must begin with 1

The full nine (9) digits of the ZIP Code are
required. If the last four (4) digits of the ZIP
code are not available, populate a default
value of “9998”.
EI
199999997

837 Institutional Companion Guide Version 29.0/May 2014

S
MA
MI

PI
80881

Employer’s Identification Number (EIN)
Institutional provider default EIN
EDSCMS is considered the destination
(secondary) payer
Must be populated with a value of MA –
Medicare Part A
Must be populated with a value of MI –
Member Identification Number
This is the subscriber’s Health Insurance Claim
(HIC) number. Must match the value in Loop
2330A, NM109
EDSCMS
Must be populated with the value of PI –
Payer Identification

LOOP ID
2010BB

REFERENCE
N3
N301

2010BB

N4
N401
N402
N403
REF

2010BB

2300

REF01
REF02
CLM
CLM02
CLM05-3

DTP
DTP02
DTP03

2300

PWK
PWK01

PWK02
2300

CN1
CN101

TABLE 4 - 837 INSTITUTIONAL HEALTH CARE CLAIM (CONTINUED)
NAME
CODES
NOTES/COMMENTS
Payer Address
Payer Address Line
7500 Security
Blvd
Payer City, State, ZIP Code
Payer City Name
Baltimore
Payer State
MD
Payer ZIP Code
212441850
Other Payer Secondary
Identifier
Contract ID Identifier
2U
Contract ID Number
MAO or other entities Contract ID Number
Claim Information
Total Claim Charge Amount
Claim Frequency Type
1
1=Original claim submission
Code
2
2=Interim – First Claim
3
3=Interim – Continuing Claim
4
4=Interim – Last Claim
7
7=Replacement
8
8=Deletion
9
9=Final Claim for a Home Health PPS Episode
Date – Admission Date/Hour
Date Time Period Format
D8
D8=CCYYMMDD
Qualifier
DT
DT=CCYYMMDDHHMM
Admission Date/Hour
Hours (HH) are expressed as “00” for
midnight, “01” for 1A.M., and so on through
“23” for 11P.M.
Minutes (MM) are expressed as “00” through
“59”. If the actual minutes are not known,
use a default of “00”.
This is only required for original or final bills
Claim Supplemental
Information
Report Type Code
09
Populated for chart review submissions only

Attachment Transmission
Code
Contract Information
Contract Type Code

837 Institutional Companion Guide Version 29.0/May 2014

Populated for encounters generated as a
result of paper claims only

Populated for encounters generated as a
result of 4010 submission only
Populated for chart review, paper generated,
and 4010 generated encounters

Populated for capitated/ staff model
arrangements
12

2300

NTE
NTE01
NTE02

2300

TABLE 4 - 837 INSTITUTIONAL HEALTH CARE CLAIM (CONTINUED)
NAME
CODES
NOTES/COMMENTS
Payer Claim Control Number
Original Reference Number
F8
Payer Claim Control Number
Identifies ICN from original encounter when
submitting adjustment or chart review data
Medical Record Number
Medical Record Identification
EA
Number
Medical Record Identification
8
Chart review delete diagnosis code only
Number
submission – Identifies the diagnosis code
populated in Loop 2300, HI must be deleted
from the encounter ICN in Loop 2300, REF02.
Deleted
Diagnosis code(s) that must be deleted from the
Diagnosis encounter ICN in Loop 2300, REF02 for “chart
Code(s)
review – add and delete specific diagnosis
codes on a single encounter” submissions only.
Claim Note
Note Reference Code
ADD
Claim Note Text
See Section 11.0 for the use and message
requirements of default data information
Value Information

HI01-2
HI01-5

Value Code
Value Code Amount

SBR
SBR01

Other Subscriber Information
Payer Responsibility Sequence
Number Code

LOOP ID
2300

REFERENCE
REF
REF01
REF02

2300

REF
REF01
REF02

2320

Required on all ambulance encounters
Must include the ambulance pick-up location
ZIP Code+4, when available, in the following
format: xxxxxxxx.x

P=Primary (when MAOs or other entities
populate the payer paid amount)
T=Tertiary (when MAOs or other entities
populate a true COB)
Health Maintenance Organization (HMO)
Medicare Risk

2330A

2330B

SBR09

Claim Filing Indicator Code

NM1
NM108
NM109
NM1
NM108
NM109

Other Subscriber Name
Identification Code Qualifier
Subscriber Primary Identifier
Other Payer Name
Identification Code Qualifier
Other Payer Primary Identifier

MI
Must match the value in Loop 2010BA, NM109
XV
Payer 01

837 Institutional Companion Guide Version 29.0/May 2014

MAO or other entity’s Contract ID Number.
Only populated if there is no Contract ID
Number available for a true other payer

LOOP ID
2330B

REFERENCE
N3
N301
N4
N401
N402
N403
SVD
SVD01
CAS
CAS02

2430
2430

2430

DTP
DTP03

TABLE 4 - 837 INSTITUTIONAL HEALTH CARE CLAIM (CONTINUED)
NAME
CODES
NOTES/COMMENTS
Other Payer Address
Other Payer Address Line
MAO or other entity’s address
Other Payer City, State, ZIP
Code
Other Payer City Name
MAO or other entity’s City Name
Other Payer State
MAO or other entity’s State
Other Payer ZIP Code
MAO or other entity’s ZIP Code
Line Adjudication Information
Other Payer Primary Identifier
Must match the value in Loop 2330B, NM109
Line Adjustments
Adjustment Reason Code
If a service line is denied in the MAO or other
entities’ adjudication system, the denial reason
must be populated
Line Check or Remittance Date
Populate the claim receipt date minus one (1)
day as the default primary payer adjudication
date only in the instance that the primary payer
adjudication date is not available

6.0

Acknowledgements and/or Reports

6.1

TA1 – Interchange Acknowledgement

The TA1 report enables the receiver to notify the sender when there are problems with the interchange
control structure. As the interchange envelope enters the EDFES, the EDI translator performs TA1
validation of the control segments/envelope. The sender will only receive a TA1 there are syntax errors
in the file. Errors found in this stage will cause the entire X12 interchange to be rejected with no further
processing.
MAOs and other entities will receive a TA1 interchange report acknowledging the syntactical inaccuracy
of an X12 interchange header ISA and trailer IEA and the envelope’s structure. Encompassed in the TA1
is the interchange control number, interchange date and time, interchange acknowledgement code, and
interchange note code. The interchange control number, date, and time are identical to those
populated on the original 837-I or 837-P ISA line, which allows for MAOs and other entities to associate
the TA1 with a specific file previously submitted.
Within the TA1 segment, MAOs and other entities will be able to determine if the interchange rejected
by examining the interchange acknowledgement code (TA104) and the interchange note code (TA105).
The interchange acknowledgement code stipulates whether the interchange (ISA/IEA) rejected due to
syntactical errors. An “R” will be the value in the TA104 data element if the interchange rejected due to
errors. The interchange note code is a numeric code that notifies MAOs and other entities of the
specific error. If a fatal error occurs, the EDFES generates and returns the TA1 interchange
acknowledgement report within 24 hours of the interchange submission. If a TA1 interchange control
structure error is identified, MAOs and other entities must correct the error and resubmit the
interchange file.

837 Institutional Companion Guide Version 29.0/May 2014

6.2

999 – Functional Group Acknowledgement

After the interchange passes the TA1 edits, the next stage of editing is to apply Implementation Guide
(IG) edits and verify the syntactical correctness of the functional group(s) (GS/GE). Functional groups
allow for organization of like data within an interchange; therefore, more than one (1) functional group
with multiple claims within the functional group can be populated in a file. The 999 acknowledgement
report provides information on the validation of the GS/GE functional group(s) and the consistency of
the data. The 999 report provides MAOs and other entities information on whether the functional
groups were accepted or rejected.
If a file has multiple GS/GE segments and errors occurred at any point within one of the syntactical and
IG level edit validations, the GS/GE segment will reject, and processing will continue to the next GS/GE
segment. For instance, if a file is submitted with three (3) functional groups and there are errors in the
second functional, the first functional group will accept, the second functional group will reject, and
processing will continue to the third functional group.
The 999 transaction set is designed to report on adherence to IG level edits and CMS standard syntax
errors as depicted in the CMS edit spreadsheet. Three (3) possible acknowledgement values are:
•
“A” – Accepted
•
“R” – Rejected
•
“P” – Partially Accepted, At Least One Transaction Set Was Rejected
When viewing the 999 report, MAOs and other entities should navigate to the IK5 and AK9 segments. If
an “A” is displayed in the IK5 and AK9 segments, the claim file is accepted and will continue processing.
If an “R” is displayed in the IK5 and AK9 segments, an IK3 and an IK4 segment will be displayed. These
segments indicate what loops and segments contain the error that needs correcting so the interchange
can be resubmitted. The third element in the IK3 segment identifies the loop that contains the error.
The first element in the IK3 and IK4 indicates the segment and element that contain the error. The third
element in the IK4 segment indicates the reason code for the error.
6.3

277CA – Claim Acknowledgement

After the file is accepted at the interchange and functional group levels, the third level of editing occurs
at the transaction set level within the CEM in order to create the Claim Acknowledgement Transaction
(277CA) report. The CEM checks the validity of the values within the data elements. For instance, data
element N403 must be a valid nine (9)-digit ZIP code. If a non-existent ZIP code is populated, the CEM
will reject the encounter. The 277CA is an unsolicited acknowledgement report from CMS to MAOs and
other entities.
The 277CA is used to acknowledge the acceptance or rejection of encounters submitted using a
hierarchical level (HL) structure. The first level of hierarchical editing is at the Information Source level.
This entity is the decision maker in the business transaction receiving the X12 837 transactions
(EDSCMS). The next level is at the Information Receiver level. This is the entity expecting the response
from the Information Source. The third hierarchal level is at the Billing Provider of Service level; and the
fourth and final level is done at the Patient level. Acceptance or rejection at this level is based on the
WPC and the CMS edits spreadsheet. Edits received at any hierarchical level will stop and no further
editing will take place. For example, if there is a problem with the Billing Provider of Service submitted
on the 837, individual patient edits will not be performed. For those encounters not accepted, the
277CA will detail additional actions required of MAOs and other entities in order to correct and resubmit
those encounters.
837 Institutional Companion Guide Version 29.0/May 2014

If an MAO or other entity receives a 277CA indicating that an encounter was rejected, the MAO or other
entity must resubmit the encounter until the 277CA indicates no errors were found.
If an encounter is accepted, the 277CA will provide the ICN assigned to that encounter. The ICN
segment for the accepted encounter will be located in 2200D REF segment, REF01=IK and REF02=ICN.
The ICN is a unique 13-digit number.
If an encounter rejects, the 277CA will provide edit information in the STC segment. The STC03 data
element will convey whether the HL structures accepted or rejected. The STC03 is populated with a
value of “WQ” if the HL was accepted. If the STC03 data element is populated with a value of “U”, the
HL is rejected and the STC01 data element will list the acknowledgement code.
6.4

MAO-001 – Encounter Data Duplicates Report

When the MAO-002 Encounter Data Processing Status Report is returned to an MAO or other entity, and
contains edit 98325 – Service Line(s) Duplicated, the EDPS will also generate and return the MAO-001
Encounter Data Duplicates Report. MAOs and other entities will not receive the MAO-001 report if
there are no duplicate errors received on submitted encounters.
The MAO-001 report is a fixed length report available in flat file and formatted report layouts. It
provides information for encounters and service lines that receive a status of “reject” and the specific
error message of 98325 – Service Line(s) Duplicated. MAOs and other entities must correct and
resubmit only those encounters containing service lines that received edit 98325. The MAO-001 report
allows MAOs and other entities the opportunity to more easily reconcile these duplicate encounters and
service lines.
6.5

MAO-002 – Encounter Data Processing Status Report

After a file accepts through the EDFES, the file is transmitted to the Encounter Data Processing System
(EDPS) where further editing, processing, pricing, and storage occurs. As a result of EDPS editing, the
EDPS will return the MAO-002 – Encounter Data Processing Status Report.
The MAO-002 report is a fixed length report available in flat file and formatted report layouts that
provide encounter and service line level information. The MAO-002 reflects two (2) statuses at the
encounter and service line level: “accepted” and “rejected”. Lines that reflect a status of “accept” yet
contain an error message in the Error Description column are considered “informational” edits. MAOs
and other entities are not required to take further action on “informational” edits.
The ‘000’ line on the MAO-002 report identifies the header level and indicates either “accepted” or
“rejected” status. If the ‘000’ header line is rejected, the encounter is considered rejected and MAOs
and other entities must correct and resubmit the encounter. If the ‘000’ header line is “accepted” and
at least one (1) other line (i.e., 001 002 003 004) is accepted, then the overall encounter is accepted.
6.6

Reports File Naming Conventions

In order for MAOs and other entities to receive and identify the EDFES acknowledge reports (TA1, 999
and 277CA) and EDPS MAO-002 Encounter Data Processing Status Report, specific reports file naming
conventions have been used. The file name ensures that the specific reports are appropriately
distributed to each secure, unique mailbox. The EDFES and EDPS have established unique file naming
conventions for reports distributed during testing and production.

837 Institutional Companion Guide Version 29.0/May 2014

6.6.1

Testing Reports File Naming Convention

Table 5 below provides the EDFES reports file naming conventions according to connectivity method.
MAOs and other entities should note that Connect:Direct (NDM) users’ reports file naming conventions
are user defined.
TABLE 5 – TESTING EDFES REPORTS FILE NAMING CONVENTIONS
REPORT TYPE
GENTRAN/TIBCO MAILBOX
FTP MAILBOX
EDFES Notifications
T.xxxxx.EDS_RESPONSE.pn
RSPxxxxx.RSP.REJECTED_ID
TA1
T.xxxxx.EDS_REJT_IC_ISAIEA.pn
X12xxxxx.X12.TMMDDCCYYHHMMS
999
T.xxxxx.EDS_REJT_FUNCT_TRANS.pn
999#####.999.999
999
T.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn
999#####.999.999
277CA
T.xxxxx.EDS_RESP_CLAIM_NUM.pn
RSPxxxxx.RSP_277CA
Table 6 below provides the EDPS reports file naming convention by connectivity method. MAOs and
other entities should note that Connect:Direct (NDM) users’ reports file naming conventions are user
defined.
TABLE 6 – TESTING EDPS REPORTS FILE NAMING CONVENTIONS
CONNECTIVITY
METHOD
GENTRAN/
TIBCO

FTP

TESTING NAMING CONVENTION
FORMATTED REPORT
T .xxxxx.EDPS_001_DataDuplicate_Rpt
T.xxxxx.EDPS_002_DataProcessingStatus_Rpt
T .xxxxx.EDPS_004_RiskFilter_Rpt
T.xxxxx.EDPS_005_DispositionSummary_Rpt
T .xxxxx.EDPS_006_EditDisposition_Rpt
T .xxxxx.EDPS_007_DispositionDetail_Rpt
RPTxxxxx.RPT.EDPS_001_DATDUP_RPT
RPTxxxxx.RPT.EDPS_002_DATPRS_RPT
RPTxxxxx.RPT.EDPS_004_RSKFLT_RPT
RPTxxxxx.RPT.EDPS_005_DSPSUM_RPT
RPTxxxxx.RPT.EDPS_006_EDTDSP_RPT
RPTxxxxx.RPT.EDPS_007_DSTDTL_RPT

TESTING NAMING CONVENTION
FLAT FILE LAYOUT
T .xxxxx.EDPS_001_DataDuplicate_File
T.xxxxx.EDPS_002_DataProcessingStatus_File
T .xxxxx.EDPS_004_RiskFilter_File
T.xxxxx.EDPS_005_DispositionSummary_ File
T .xxxxx.EDPS_006_EditDisposition_ File
T .xxxxx.EDPS_007_DispositionDetail_ File
RPTxxxxx.RPT.EDPS_001_DATDUP_File
RPTxxxxx.RPT.EDPS_002_DATPRS_File
RPTxxxxx.RPT.EDPS_004_RSKFLT_ File
RPTxxxxx.RPT.EDPS_005_DSPSUM_ File
RPTxxxxx.RPT.EDPS_006_EDTDSP_ File
RPTxxxxx.RPT.EDPS_007_DSTDTL_ File

Table 7 below provides a description of the file name components, which will assist MAOs and other
entities in identifying the report type.
FILE NAME
COMPONENT
RSPxxxxx
X12xxxxx
TMMDDCCYYHHMMS
999xxxxx
RPTxxxxx
EDPS_XXX
XXXXXXX
RPT/FILE

TABLE 7 –FILE NAME COMPONENT DESCRIPTION
DESCRIPTION
The type of data ‘RSP’ and a sequential number assigned by the server ‘xxxxx’
The type of data ‘X12’ and a sequential number assigned by the server ‘xxxxx’
The Date and Time stamp the file was processed
The type of data ‘999’ and a sequential number assigned by the server ‘xxxxx’
The type of data ‘RPT’ and a sequential number assigned by the server ‘xxxxx’
Identifies the specific EDPS Report along with the report number (i.e., ‘002’, etc.)
Seven (7) characters available to be used as a short description of the contents of the file
Identifies if the file is a formatted report ‘RPT’ or a flat file ‘FILE’ layout

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6.6.2

Production Reports File Naming Convention

A different production reports file naming convention is used so that MAOs and other entities may easily
identify reports generated and distributed during production. Table 8 below provides the reports file
naming conventions per connectivity method for production reports.
REPORT TYPE
EDFES Notifications
TA1
999
999
277CA

TABLE 8 – PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS
GENTRAN/TIBCO MAILBOX
FTP MAILBOX
P.xxxxx.EDS_RESPONSE.pn
RSPxxxxx.RSP.REJECTED_ID
P.xxxxx.EDS_REJT_IC_ISAIEA.pn
X12xxxxx.X12.TMMDDCCYYHHMMS
P.xxxxx.EDS_REJT_FUNCT_TRANS.pn
999#####.999.999
P.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn
999#####.999.999
P.xxxxx.EDS_RESP_CLAIM_NUM.pn
RSPxxxxx.RSP_277CA

Table 9 below provides the production EDPS reports file naming conventions per connectivity method.
TABLE 9 – PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS
CONNECTIVITY
METHOD
GENTRAN/
TIBCO

FTP

6.7

PRODUCTION NAMING CONVENTION
FORMATTED REPORT
P.xxxxx.EDPS_001_DataDuplicate_Rpt
P.xxxxx.EDPS_002_DataProcessingStatus_Rpt
P.xxxxx.EDPS_004_RiskFilter_Rpt
P.xxxxx.EDPS_005_DispositionSummary_Rpt
P.xxxxx.EDPS_006_EditDisposition_Rpt
P.xxxxx.EDPS_007_DispositionDetail_Rpt
RPTxxxxx.RPT.PROD_001_DATDUP_RPT
RPTxxxxx.RPT.PROD_002_DATPRS_RPT
RPTxxxxx.RPT.PROD_004_RSKFLT_RPT
RPTxxxxx.RPT.PROD_005_DSPSUM_RPT
RPTxxxxx.RPT.PROD_006_EDTDSP_RPT
RPTxxxxx.RPT.PROD_007_DSTDTL_RPT

PRODUCTION NAMING CONVENTION
FLAT FILE LAYOUT
P.xxxxx.EDPS_001_DataDuplicate_File
P.xxxxx.EDPS_002_DataProcessingStatus_File
P.xxxxx.EDPS_004_RiskFilter_File
P.xxxxx.EDPS_005_DispositionSummary_ File
P.xxxxx.EDPS_006_EditDisposition_ File
P.xxxxx.EDPS_007_DispositionDetail_ File
RPTxxxxx.RPT.PROD_001_DATDUP_File
RPTxxxxx.RPT.PROD_002_DATPRS_File
RPTxxxxx.RPT.PROD_004_RSKFLT_ File
RPTxxxxx.RPT.PROD_005_DSPSUM_ File
RPTxxxxx.RPT.PROD_006_EDTDSP_ File
RPTxxxxx.RPT.PROD_007_DSTDTL_ File

EDFES Notifications

The EDFES distributes special notifications to submitters when encounters have been processed by the
EDFES, but will not proceed to the EDPS for further processing. These notifications are distributed to
MAOs and other entities, in addition to standard EDFES Acknowledgement Reports (TA1, 999, and
277CA) in order to avoid returned, unprocessed files from the EDS.
Table 10 below provides the file type, EDFES notification message, and EDFES notification message
description.
The file has an 80 character record length and contains the following record layout:
1. File Name Record
a. Positions 1 – 7 = Blank Spaces
b. Positions 8 – 18 = File Name:
c. Positions 19 – 62 = Name of the Saved File
d. Positions 63 – 80 = Blank Spaces
2. File Control Record
a. Positions 1 – 4 = Blank Spaces
b. Positions 5 – 18 = File Control:
837 Institutional Companion Guide Version 29.0/May 2014

4.
5.
6.

c. Positions 19 – 27 = File Control Number
d. Positions 28 – 80 = Blank Spaces
File Count Record
a. Positions 1 – 18 = Number of Claims:
b. Positions 19 – 24 = File Claim Count
c. Positions 25 – 80 = Blank Spaces
File Separator Record
a. Positions 1 – 80 = Separator (----------)
File Message Record
a. Positions 1 – 80 = FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE
FOLLOWING REASON(S)
File Message Records
a. Positions 1 – 80 = File Message

The report format example is as follows:
FILE NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
FILE CONTROL: XXXXXXXXX
NUMBER OF CLAIMS: 99,999
FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Table 10 provides the complete list of testing and production EDFES notification messages.
TABLE 10 – EDFES NOTIFICATIONS
APPLIES TO

ENCOUNTER TYPE

NOTIFICATION MESSAGE
FILE ID (XXXXXXXXX) IS A
DUPLICATE OF A FILE ID SENT
WITHIN THE LAST 12 MONTHS
SUBMITTER NOT AUTHORIZED
TO SEND CLAIMS FOR PLAN
(CONTRACT ID)

All files submitted

All

All files submitted

All

All files submitted

All

PLAN ID CANNOT BE THE SAME
AS THE SUBMITTER ID

All

AT LEAST ONE ENCOUNTER IS
MISSING A CONTRACT ID IN THE
2010BB-REF02 SEGMENT

All files submitted

All

SUBMITTER NOT FRONT-END
CERTIFIED

Production files submitted

All

SUBMITTER NOT CERTIFIED FOR
PRODUCTION

Tier 2 files submitted

All

THE INTERCHANGE USAGE
INDICATOR MUST EQUAL ‘T’

837 Institutional Companion Guide Version 29.0/May 2014

NOTIFICATION MESSAGE
DESCRIPTION
The file ID must be unique
for a 12 month period
The submitter is not
authorized to send for this
plan
The Contract ID cannot be
the same as the Submitter
ID
The Contract ID is missing
The submitter must be
front-end certified to send
encounters for validation or
production
The submitter must be
certified to send
encounters for production
The Institutional Tier 2 file
is being sent with a ‘P’ in
the ISA15 field

TABLE 10 – EDFES NOTIFICATIONS (CONTINUED)
APPLIES TO
Tier 2 file submitted
Institutional End-to-End
Testing – File 1
Institutional End-to-End
Testing – Additional File(s)
PACE End-to-End Testing –
File 1
PACE End-to-End Testing –
Additional File(s)

PLAN (CONTRACT ID) HAS
(X,XXX) CLAIMS IN THIS FILE.
ONLY 2,000 ARE ALLOWED

NOTIFICATION MESSAGE
DESCRIPTION
The number of encounters
for a Contract ID cannot be
greater than 2,000

Institutional

FILE CANNOT CONTAIN MORE
THAN 24 ENCOUNTERS

The number of encounters
cannot be greater than 24

PACE Institutional

FILE CANNOT CONTAIN MORE
THAN 14 ENCOUNTERS

The number of encounters
cannot be greater than 14

PATIENT CONTROL NUMBER IS
MORE THAN 20 CHARACTERS
LONG THE TC# WAS
TRUNCATED
FILE CANNOT CONTAIN BOTH
UNLINKED AND LINKED TEST
CASES
CANNOT SEND LINKED TEST
CASES UNTIL ALL UNLINKED
TEST CASES HAVE BEEN
ACCEPTED
FILE CONTAINS (X) TEST CASE (X)
ENCOUNTER(S)

The Claim Control Number,
including the Test Case
Number, must not exceed 20
characters
The test cases from File 1 and
File 2 cannot be in the same
file

ENCOUNTER TYPE
All

End-to-End Testing – File 1
End-to-End Testing –
Additional File(s)

All

End-to-End Testing – File 1
End-to-End Testing –
Additional File(s)

Institutional, PACE
Institutional

End-to-End Testing – File 1
End-to-End Testing –
Additional File(s)

Institutional, PACE
Institutional

End-to-End Testing – File 1

All

Test

All

End-to-End Testing –
Additional File(s)

All

All files submitted

All

All files submitted

All

All files submitted
7.0

All

NOTIFICATION MESSAGE

NO TEST CASES FOUND IN THIS
FILE
ADDITIONAL FILES CANNOT BE
VALIDATED UNTIL AN MAO-002
REPORT HAS BEEN RECEIVED
FILE CANNOT EXCEED 5,000
ENCOUNTERS
TRANSACTION SET (ST/SE)
(XXXXXXXXX) CANNOT EXCEED
5,000 CLAIMS
DATE OF SERVICE CANNOT BE
BEFORE 2011

The test cases for File 2
cannot be sent before all File
1 test cases are accepted
The file must contain two (2)
of each test case
This file was processed with
the Interchange Usage
Indicator = ‘T’ and the
Submitter was not yet FrontEnd Certified
The MAO-002 report must be
received before additional
files can be submitted
The maximum number of
encounters allowed in a file
There can only be 5,000
claims in each ST/SE Loop
Files cannot be submitted
with a date of service before
2011

Front-End Edits

CMS provides a list of the edits used to process all encounters submitted to the EDFES. The Fee-forService (FFS) Institutional CEM Edits Spreadsheet identifies currently active and deactivated edits for
MAOs and other entities to reference for programming their internal systems and reconciling EDFES
Acknowledgement Reports.
837 Institutional Companion Guide Version 29.0/May 2014

The Institutional CEM Edits Spreadsheet provides documentation regarding edit rules that explain how
to identify an EDFES edit and the associated logic. The Institutional CEM Edits Spreadsheet also provides
a change log that lists the revision history for edit updates.
MAOs and other entities are able to access the Institutional CEM Edits Spreadsheet on the CMS website
at https://www.cms.gov/Medicare/Billing/MFFS5010D0/Technical-Documentation.html and on the
CSSC Operations website at:
http://www.csscoperations.com/internet/cssc3.nsf/docsCat/CSSC~CSSC%20Operations~Encounter%20
Data~Resources?open&expand=1&navmenu=Encounter^Data||,
7.1

Deactivated Front-End Edits

Several CEM edits currently active in the FFS Institutional CEM edits spreadsheet will be deactivated in
order to ensure that syntactically correct encounters pass front-edit editing. Table 11 provides a list of
the deactivated EDFES CEM edits. The edit reference column provides the exact reference for the
deactivated edits. The edit description column provides the Claim Status Category Code (CSCC), the
Claim Status Code (CSC), and the Entity Identifier Code (EIC), when applicable. The notes column
provides a description of the edit reason. MAOs and other entities should reference the WPC website at
www.wpc-edi.com for a complete listing of all CSCCs and CSCs.
TABLE 11 - 837 INSTITUTIONAL DEACTIVATED EDFES EDITS
EDIT REFERENCE
EDIT DESCRIPTION
EDIT NOTES
X223.084.2010AA.NM109.040 CSCC A8: "Acknowledgement /
Valid NPI Crosswalk must be available for this
Rejected for relational field in error." edit.
CSC 562: "Entity's National Provider
2010AA.NM109 must be a valid NPI on the
Identifier (NPI)"
Crosswalk when evaluated with 1000B.NM109.
EIC: 85 Billing Provider
X223.084.2010AA.NM109.050 CSCC A8: "Acknowledgement /
This Fee for Service edit validates the NPI and
Rejected for relational field in error" submitter ID number to ensure the submitter is
CSC 496 "Submitter not approved for authorized to submit on the provider’s behalf.
electronic claim submissions on
Encounter data cannot use this validation as we
behalf of this entity."
validate the plan number and submitter ID to
EIC: 85 Billing Provider
ensure the submitter is authorized to submit on
the plans behalf.

X223.087.2010AA.N301.070

X223.090.2010AA.REF02.050

CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 503: "Entity's Street Address"
EIC: 85 Billing Provider
CSCC A8: "Acknowledgement /
Rejected for relational field in error"
CSC 562: "Entity's National Provider
Identifier (NPI)"
CSC 128: "Entity's tax id"
EIC: 85 Billing Provider

837 Institutional Companion Guide Version 29.0/May 2014

2010AA.NM109 billing provider must be
"associated" to the submitter (from a trading
partner management perspective) in
1000A.NM109.
Remove edit check for 2010AA N3 PO Box
variations when ISA08 = 80881 (Institutional
Payer Code).
Valid NPI Crosswalk must be available for this
edit.
2010AA.REF must be associated with the
provider identified in 2010AA.NM109.

TABLE 11 - 837 INSTITUTIONAL DEACTIVATED EDFES EDITS (CONTINUED)
EDIT REFERENCE
EDIT DESCRIPTION
EDIT NOTES
X223.127.2010BB.REF.010
CSCC A7: "Acknowledgement
This REF Segment is used to capture the Plan
/Rejected for Invalid Information…"
number as this is unique to Encounter
CSC 732: "Information submitted
Submission only. The CEM has the following
inconsistent with billing guidelines."
logic that is applied:
CSC 560: "Entity's
Non-VA claims: 2010BB.REF with REF01 = "2U",
Additional/Secondary Identifier."
"EI", "FY" or "NF" must not be present.
EIC: PR "Payer"
VA claims: 2010BB.REF with REF01 = "EI", "FY"
or "NF" must not be present.
This edit needs to remain off in order for the
submitter to send in his plan number.
X223.143.2300.CLM02.020
IK403 = 6: "Invalid Character in Data
2300.CLM02 must be numeric.
Element"
X223.424.2400.SV202-7.025

CSCC A8: "Acknowledgement /
Rejected for relational field in error"
CSC 306 Detailed description of
service 2400.SV202-7 must be
present when 2400.SV202-2 contains
a non-specific procedure code.

X223.109.2000B.SBR03.040
X223.109.2000B.SBR03.050

CSCC A8: Acknowledgement/
Rejected for relational field in error
CSC 163: Entity’s Policy Number
CSC 732: Information submitted
inconsistent with billing guidelines
EIC IL: Subscriber
CSCC A8:
Acknowledgement/Rejected for
relational field in error
CSC 663: Entity's Group Name
CSC 732: Information submitted
inconsistent with billing guidelines
EIC IL: Subscriber
CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 234: "Patient discharge status"

X223.109.2000B.SBR04.004
X223.109.2000B.SBR04.007

X223.153.2300.CL103.015

X223.364.2320.AMT.040

When using a not otherwise classified or
generic HCPCS procedure code the CEM is
editing for a more descriptive meaning of the
procedure code. For example, the submitter is
using J3490. The description for this HCPCS is
Not Otherwise Classified (NOC) Code. CMS has
made a decision not to price claims with these
types of codes.

When 2300.CL103 value “20”, “40”, “41”, or
“42” is present, at least one occurrence of
2300.HI01-2 thru HI12-2 must = “55” where
HI01-1 is “BH”.

CSCC A7:
Acknowledgement/Rejected for
Invalid Information
CSC 41: Special handling required at
payer site
CSC 286: Other Payer's Explanation of
Benefits/payment information
CSC 732: Information submitted
inconsistent with billing guidelines

837 Institutional Companion Guide Version 29.0/May 2014

TABLE 11 - 837 INSTITUTIONAL DEACTIVATED EDFES EDITS (CONTINUED)
EDIT REFERENCE
EDIT DESCRIPTION
EDIT NOTES
X223.424.2400.SV203.060
CSCC A7: "Acknowledgement
SV203 must = the sum of all payer amounts
/Rejected for Invalid Information…"
paid found in 2430 SVD02 and the sum of all
CSC 400: "Claim is out of balance:
line adjustments found in 2430 CAS Adjustment
CSC 583:"Line Item Charge Amount"
Amounts.
CSC 643: "Service Line Paid Amount"
X223.476.2430.SVD02.020
IK403 = 6: Invalid Character in Data
Element

7.2

Temporarily Deactivated Front-End Edits

Table 12 provides a list of the temporarily deactivated EDFES Institutional CEM balancing edits in order
to ensure that encounters that require balancing of monetary fields will pass front-end editing.
Note: The Institutional edits listed in Table 12 are not all-inclusive and are subject to amendment.
TABLE 12 – 837 INSTITUTIONAL TEMPORARILY DEACTIVATED CEM EDITS
EDIT REFERENCE
EDIT DESCRIPTION
EDIT NOTES
X223.143.2300.CLM02.080
CSCC A7: "Acknowledgement
CLM02 must equal the sum of all 2320 CAS
/Rejected for Invalid Information…"
amounts & all 2430 CAS amounts and 2320
CSC 400: "Claim is out of Balance"
AMT02 (when AMT01=D).
CSC 672 "Payer's payment information
is out of balance
X223.143.2300.CLM02.070

CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 400: "Claim is out of balance"
CSC 178: "Submitted Charges"

2300.CLM02 must = the sum of all 2400.SV203
amounts.

X223.424.2400.SV202-7.025

CSCC A8: "Acknowledgement /
Rejected for relational field in error"
CSC 306 Detailed description of
service 2400.SV202-7 must be
present when 2400.SV202-2 contains
a non-specific procedure code.

8.0

Duplicate Logic

In order to ensure encounters submitted are not duplicates of encounters previously submitted, the EDS
will perform header and detail level duplicate checking. If the header and/or detail level duplicate
checking determines that the file is a duplicate, the file will reject, and an error report will be returned
to the submitter.
8.1

Header Level

When a file (ISA/IEA) is received, the system assigns a hash total to the file based on the entire ISA/IEA
interchange. The EDS uses hash totals to ensure the accuracy of processed data. The hash total is a
total of several fields or data in a file, including fields not normally used in calculations, such as the
837 Institutional Companion Guide Version 29.0/May 2014

account number. At various stages in processing, the hash total is recalculated and compared with the
original. If a file comes in later in a different submission, or a different submission of the same file, and
gets the same hash total, it will reject as a duplicate.
In addition to the hash total, the system also references the values collectively populated in ISA13, GS06,
ST02, and BHT03. If two (2) files are submitted with the exact same values populated as a previously
submitted and accepted file, the file will be considered a duplicate and the error message CSCC - A8 =
Acknowledgement / Rejected for relational field in error, CSC -746 = Duplicate Submission will be
provided on the 277CA.
8.2

Detail Level

Once an encounter passes through the Institutional or Professional processing and pricing system, it is
stored in an internal repository, the Encounter Operational Data Store (EODS). If a new encounter is
submitted that matches specific values on another stored encounter, the encounter will reject as a
duplicate encounter. The encounter will be returned to the submitter with an error message identifying
it as a duplicate encounter. Currently, the following values are the minimum set of items used for
matching an encounter in the EODS:
•
•
•
•
•
•
•

Beneficiary Demographic
o Health Insurance Claim Number (HICN)
o Name
Date of Service
Type of Bill (TOB)
Revenue Code(s)
Procedure Code(s) and 4 modifiers
Billing Provider NPI
Paid Amount*

* Paid Amount is the amount paid by the MAO or other entity and should be populated in Loop ID-2320,
AMT02.

837 Institutional Companion Guide Version 29.0/May 2014

9.0

837 Institutional Business Cases

In accordance with 45 CFR 160.103 of the HIPAA, Protected Health Information (PHI) has been removed
from all business cases. As a result, the business cases have been populated with fictitious information
about the Subscriber, MAO, and provider(s). The business cases reflect 2012 dates of service.
Although the business cases are provided as examples of possible encounter submissions, MAOs and
other entities must populate valid data in order to successfully pass translator and CEM level editing.
MAOs and other entities should direct questions regarding the contents of the EDS Test Case
Specification to [email protected].
Note: The business cases identified in the CMS EDS 837-I Companion Guide indicate paid amounts and
DTP segments at the line level.
The Adjudication or Payment Date (DTP 573 segment) must follow the paid amount. For example, if the
paid amount is populated at the claim level, the DTP 573 segment must be populated at the claim
level. If the paid amount is populated at the line level, the DTP 573 segment must be populated at the
line level.

837 Institutional Companion Guide Version 29.0/May 2014

9.1

Standard Institutional Encounter

Business Scenario 1: Mary Dough is the patient and the subscriber, and was admitted into
Mercy Hospital because she was complaining of heart pain. Happy Health Plan was the MAO.
Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and
diabetes as an additional diagnosis.
File String 1:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*31*X*005010X223A2~
ST*837*0034*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY HOSPITAL*****XX*1299999999~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578798A*200.00***11:A:1**A*Y*Y~
DTP*096*TM*0958~
DTP*434*RD8*20120330-20120331~
DTP*435*D8*20120330~
CL1*2*9*01~
HI*BK:4280~
HI*BJ:4280~
HI*BF:25000~
HI*BR:3121:D8:20120330~
HI*BH:41:D8:20110501*BH:27:D8:20110715*BH:33:D8:20110718*BH:C2:D8:20110729~
HI*BE:30:::20~
HI*BG:01~
NM1*71*1*JONES*AMANDA*AL***XX*1005554104~
SBR*P*18*XYZ1234567******16~
837 Institutional Companion Guide Version 29.0/May 2014

AMT*D*200.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV2*0300*HC:81099*200.00*UN*1~
DTP*472*D8*20120330~
SVD*H9999*200.00*HC:81099*0300*1~
DTP*573*D8*20120401~
SE*50*0034~
GE*1*31~
IEA*1*000000031~

837 Institutional Companion Guide Version 29.0/May 2014

9.2

Capitated Institutional Encounter

Business Scenario 2: Mary Dough is the patient and the subscriber, and went to Mercy Hospital
because she was experiencing leg pain. Happy Health Plan was the MAO and has a capitated
arrangement with Mercy Hospital. Mercy Hospital diagnosed Mary with diabetes and leg pain.
File String 2:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000331*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*30*X*005010X223A2~
ST*837*0021*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY HOSPITAL*****XX*1299999999~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578798A *0.00***11:A:1**A*Y*Y~
DTP*096*TM*0958~
DTP*434*RD8*20120330-20120331~
DTP*435*D8*20120330~
CL1*2*9*01~
CN1*05~
HI*BK:4280~
HI*BJ:4280~
HI*BF:25000~
HI*BR:3121:D8:20120330~
HI*BH:41:D8:20110501*BH:27:D8:20110715*BH:33:D8:20110718*BH:C2:D8:20110729~
HI*BE:30:::20~
HI*BG:01~
NM1*71*1*JONES*AMANDA*AL***XX*1005554104~
SBR*P*18*XYZ1234567******ZZ~
837 Institutional Companion Guide Version 29.0/May 2014

AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
LX*1~
SV2*0300*HC:81099*0.00*UN*1~
DTP*472*D8*20120330~
SVD*H9999*100.50*HC:81099*0300*1~
CAS*CO*24*-100.50~
DTP*573*D8*20120401~
SE*50*0021~
GE*1*30~
IEA*1*000000331~

837 Institutional Companion Guide Version 29.0/May 2014

9.3

Chart Review Institutional Encounter – No Linked ICN

Business Scenario 3: Mary Dough is the patient and the subscriber, and went to Mercy Hospital
because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan
performs a chart review at Mercy Hospital and determines that a diagnosis for Mary Dough was
never submitted on a claim. The medical record does not contain enough information to
submit a full claim, yet there is enough information to support the diagnosis and link the chart
review encounter back to the medical record. Happy Health Plan submits a chart review
encounter with no linked ICN to add the diagnosis.
File String 3:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*31*X*005010X223A2~
ST*837*0034*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY HOSPITAL*****XX*1299999899~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578798A*0.00***11:A:1**A*Y*Y~
DTP*096*TM*0958~
DTP*434*RD8*20120330-20120331~
DTP*435*D8*20120330~
CL1*2*9*01~
PWK*09*AA~
HI*BK:4280~
HI*BJ:4280~
HI*BF:25000~
HI*BR:3121:D8:20120330~
HI*BH:41:D8:20110501*BH:27:D8:20110715*BH:33:D8:20110718*BH:C2:D8:20110729~
837 Institutional Companion Guide Version 29.0/May 2014

HI*BE:30:::20~
HI*BG:01~
NM1*71*1*JONES*AMANDA*AL***XX*1005554104~
SBR*P*18*XYZ1234567******16~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV2*0300*HC:81099*0.00*UN*1~
SVD*H9999*65.00*HC:81099**1~
DTP*472*D8*20120330~
SE*49*0034~
GE*1*31~
IEA*1*000000031~

837 Institutional Companion Guide Version 29.0/May 2014

9.4

Chart Review Institutional Encounter – Linked ICN

Business Scenario 4: Mary Dough is the patient and the subscriber, and went to Mercy Hospital
because she was experiencing leg pain. Happy Health Plan was the MAO. Mercy Hospital
submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan
performs a chart review related to ICN 1294598098746 and determines that there is an
incorrect NPI was populated for the Billing Provider.
File String 4:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*31*X*005010X223A2~
ST*837*0034*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY HOSPITAL*****XX*1299999899~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578798A*0.00***11:A:1**A*Y*Y~
DTP*096*TM*0958~
DTP*434*RD8*20120330-20120331~
DTP*435*D8*20120330~
CL1*2*9*01~
PWK*09*AA~
REF*F8*1294598098746~
HI*BK:4280~
HI*BJ:4280~
HI*BF:25000~
HI*BR:3121:D8:20120330~
HI*BH:41:D8:20110501*BH:27:D8:20110715*BH:33:D8:20110718*BH:C2:D8:20110729~
HI*BE:30:::20~
837 Institutional Companion Guide Version 29.0/May 2014

HI*BG:01~
NM1*71*1*JONES*AMANDA*AL***XX*1005554106~
SBR*P*18*XYZ1234567******16~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV2*0300*HC:81099*0.00*UN*1~
SVD*H9999*87.50*HC:81099**1~
DTP*472*D8*20120330~
SE*50*0034~
GE*1*31~
IEA*1*000000031~

837 Institutional Companion Guide Version 29.0/May 2014

9.5

Complete Replacement Institutional Encounter

Business Scenario 5: Mary Dough is the patient and the subscriber, and went to Mercy Hospital
because she was experiencing heart pain. Happy Health Plan is the MAO. Mercy Hospital
diagnosed Mary with Congestive Heart Failure and diabetes. Happy Health Plan submits the
encounter to CMS and receives an ICN 1122978564098. After further investigation, it was
determined that Happy Health Plan should not have paid for $120.00. Happy Health Plan
submits a correct and replace adjustment encounter to replace encounter 1122978564098 with
the newly submitted encounter.
File String 5:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000554*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*80*X*005010X223A2~
ST*837*0567*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY HOSPITAL*****XX*1299999999~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578798A*200.00***11:A:7**A*Y*Y~
DTP*096*TM*0958
DTP*434*RD8*20120330-20120331~
DTP*435*D8*20120330-20120331~
CL1*2*9*01~
REF*F8*1222978564098~
HI*BK:4280~
HI*BJ:4280~
HI*BR:3121:D8:20120330~
HI*BH:41:D8:20110501*BH:27:D8:20110715*BH:33:D8:20110718*BH:C2:D8:20110729~
HI*BE:30:::20~
837 Institutional Companion Guide Version 29.0/May 2014

HI*BG:01~
NM1*71*1*JOHNSON*AMANDA*AL***XX*1005554104~
SBR*P*18*XYZ1234567******16~
CAS*CO*39*120.00~
AMT*D*80.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235048769~
LX*1~
SV2*0300*HC:81099*200.00*UN*1~
DTP*472*D8*20120330~
SVD*H9999*0.00*HC:99212**1~
DTP*573*20120401~
SE*50*0567~
GE*1*80~
IEA*1*000000554~

837 Institutional Companion Guide Version 29.0/May 2014

9.6

Complete Deletion Institutional Encounter

Business Scenario 6: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth
A. Smart because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr.
Smart diagnosed Mary with abdominal pain. Happy Health Plan submits the encounter to CMS
and receives ICN 1212487000032. Happy Health Plan then determines that they mistakenly
sent the encounter without it being adjudicated in their internal system, so they want to delete
the encounter. Happy Health Plan submits an adjustment encounter to delete the previously
submitted encounter 1212487000032.
File String 6:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120430*114
4*^*00501*000000298*1*P*:~
GS*HC*ENH9999*80881*20120430*1144*82*X*005010X222A1~
ST*837*0290*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*1*SMART*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*765879876~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:8*Y*A*Y*Y~
REF*F8*1212487000032~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
CAS*CO*223*100.50~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
837 Institutional Companion Guide Version 29.0/May 2014

N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~

SV2*HC:99212*100.50*UN*1***1~

DTP*472*D8*20120401~
SVD*H9999*0.00*HC:99212**1~
DTP*573*D8*20120403~
SE*41*0290~
GE*1*82~
IEA*1*000000298~

837 Institutional Companion Guide Version 29.0/May 2014

9.7

Atypical Provider Institutional Encounter

Business Scenario 7: Mary Dough is the patient and the subscriber, and receives services from
an atypical provider. Happy Health Plan was the MAO.
File String 7:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000032*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*35*X*005010X223A2~
ST*837*0039*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY SERVICES*****XX*1999999976~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*199999997~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578799A*50.00***83:A:1**A*Y*Y~
DTP*434*RD8*20120330-20120331~
CL1*9*9*01~
HI*BK:78099~
NTE*ADD* NO NPI ON PROVIDER CLAIM NO EIN ON PROVIDER CLAIM~
SBR*P*18*XYZ1234567******16~
AMT*D*50.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
837 Institutional Companion Guide Version 29.0/May 2014

SV2*0300*HC:D0999*50.00*UN*1~
DTP*472*D8*20120330~
SVD*H9999*50.00*HC:D0999*0300*1~
DTP*573*D8*20120401~
SE*41*0039~
GE*1*35~
IEA*1*000000032~

837 Institutional Companion Guide Version 29.0/May 2014

9.8

Paper Generated Institutional Encounter

Business Scenario 8: Mary Dough is the patient and the subscriber, and receives services from
Mercy Health Plan. Mercy Health Plan submits the claim to Happy Health Plan on a UB-04.
Happy Health Plan is the MAO and converts the paper claim into an electronic submission.
File String 8:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000032*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*35*X*005010X223A2~
ST*837*0039*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY SERVICES*****XX*1234999999~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*128752354~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*22350578967509876984536578799A*50.00***83:A:1**A*Y*Y~
DTP*434*RD8*20120330-20120331~
CL1*9*9*01~
PWK*OZ*AA~
HI*BK:78099~
SBR*P*18*XYZ1234567******16~
AMT*D*50.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
837 Institutional Companion Guide Version 29.0/May 2014

LX*1~
SV2*0300*HC:D0999*50.00*UN*1~
DTP*472*D8*20120330~
SVD*H9999*50.00*HC:D0999*0300*1~
DTP*573*D8*20120403~
SE*42*0039~
GE*1*35~
IEA*1*000000032~

837 Institutional Companion Guide Version 29.0/May 2014

9.9

True Coordination of Benefits Institutional Encounter

Business Scenario 9: Mary Dough is the patient and the subscriber and was admitted into
Mercy Hospital because she was complaining of heart pain. Happy Health Plan was the MAO.
Other Health Plan also provided payment for Mary Dough. Mercy Hospital diagnosed Mary
with Congestive Health Failure as the primary diagnosis and diabetes.
File String 9:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*31*X*005010X223A2~
ST*837*0034*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY HOSPITAL*****XX*1299999999~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578799A*712.00***11:A:1**A*Y*Y~
DTP*096*TM*0958~
DTP*434*RD8*20120330-20120331~
DTP*435*D8*20120330~
CL1*2*9*01~
HI*BK:78901~
NM1*71*1*JONES*AMANDA*AL***XX*1005554104~
SBR*P*18*XYZ1234567******16~
AMT*D*700.00
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
837 Institutional Companion Guide Version 29.0/May 2014

N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
SBR*T*18*XYZ3489388******16~
CAS*CO*223*700.00~
AMT*D*12.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*OTHER HEALTH PLAN*****XV*PAYER01~
N3*400 W 21 ST~
N4*NORFOLK*VA*235059999~
DTP*573*D8*20120401~
REF*T4*Y
LX*1~
SV2*0300*HC:81099*712.00*UN*1~
DTP*472*D8*20120330~
SVD*H9999*700.00*HC:D0999*0300*1~
CAS*CO*45*12.00~
DTP*573*D8*20120401~
SE*56*0034~
GE*1*31~
IEA*1*000000031~

837 Institutional Companion Guide Version 29.0/May 2014

9.10

Bundled Institutional Encounter

Business Scenario 10: Mary Dough is the patient and the subscriber and was admitted into
Mercy Hospital because she was complaining of heart pain. Happy Health Plan was the MAO.
Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and
diabetes.
File String 10:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80881
*120816*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80881*20120816*1144*31*X*005010X223A2~
ST*837*0034*005010X223A2~
BHT*0019*00*3920394930203*20120814*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80881~
HL*1**20*1~
NM1*85*2*MERCY HOSPITAL*****XX*1299999999~
N3*876 MERCY DRIVE~
N4*NORFOLK*VA*235089999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567******MA~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80881~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850
REF*2U*H9999~
CLM*22350578967509876984536578798A*100.00***11:A:1**A*Y*Y~
DTP*096*TM*0958~
DTP*434*RD8*20120330-20120331~
DTP*435*D8*20120330~
CL1*2*9*01~
HI*BK:4280~
HI*BJ:4280~
HI*BF:25000~
HI*BR:3121:D8:20120330~
HI*BH:41:D8:20110501*BH:27:D8:20110715*BH:33:D8:20110718*BH:C2:D8:20110729~
HI*BE:30:::20~
HI*BG:01~
NM1*71*1*JONES*AMANDA*AL***XX*1005554104~
SBR*P*18*XYZ1234567******16~
837 Institutional Companion Guide Version 29.0/May 2014

AMT*D*9.48~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV2*HC:82374*50.00*UN*1***1~
DTP*472*D8*20120401~
SVD*H9999*9.48*HC:80051**1~
CAS*CO*45*40.52~
DTP*573*D8*20120403~
LX*2~
SV2*HC:82435*50.00*UN*1*11~
DTP*472*D8*20120401~
SVD*H9999*0.00*HC:80051**1*1~
CAS*OA*97*50.00~
DTP*573*D8*20120403~
SE*57*0034~
GE*1*31~
IEA*1*000000031~

837 Institutional Companion Guide Version 29.0/May 2014

10.0

Encounter Data Institutional Processing and Pricing System Edits

After an Institutional encounter passes translator and CEM level editing and receives an ICN on the
277CA acknowledgement report, the EDFES then transfers the encounter to the Encounter Data
Institutional Processing and Pricing System (EDIPPS), where editing, processing, pricing, and storage
occurs. In order to assist MAOs and other entities with submission of encounter data through the
EDIPPS, CMS has provided the current list of the EDIPPS edits identified in Table 13.
Note: The edit descriptions listed in Table 13 were revised to identify a maximum of 41 characters in
order to display a more comprehensive explanation of edits on the MAO-002 Reports.
The EDIPPS edits are organized in nine (9) different categories, as provided in Table 13, Column 2. The
EDIPPS edit categories include the following:
•
•
•
•
•
•
•
•
•

Validation
Provider
Beneficiary
Reference
Limit
Conflict
Pricing
Duplicate
NCCI

Table 13, Column 3 identifies two (2) edit dispositions: Informational and Reject. Informational edits
will cause the encounter to be flagged; 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 entity must resubmit the encounter through the EDFES. The encounter must then pass translator
and CEM level editing prior to transferring the data to the EDIPPS for reprocessing. The EDIPPS edit
description, as found in Table 13, Column 4, is included on the EDPS transaction reports to provide
further information for the MAO or other entity to identify the specific 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 encounter
is accepted. If there is no reject edit at the header level, but all lines reject, then the encounter will
reject. If there is a reject edit at the header level, the encounter will reject.
Table 13 reflects only the currently programmed EDIPPS edits. MAOs and other entities should note
that, as testing progresses, it may be determined that the current edits require modifications, additional
edits may be necessary, or edits may be deactivated. MAOs and other entities must always reference
the most recent version of the CMS EDS 837-I Companion Guide to determine the current edits in the
EDIPPS.

837 Institutional Companion Guide Version 29.0/May 2014

EDIPPS
EDIT#
00010
00011
00012
00025
00175
00265
00699
00750
00755
00760
00761
00762
00764
00765
01405
01415
02106
02110
02112
02120
02125
02240
02255
02256
02260
03022
17085
17100
17257
17310
17330
17404
17407
17595
17735
18010
18012
18018
18120
18121

TABLE 13 - ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS
EDIPPS EDIT
EDIPPS EDIT
EDIPPS EDIT ERROR MESSAGE
CATEGORY
DESCRIPTION
Validation
Reject
From DOS Greater Than TCN Date
Validation
Reject
Missing DOS in Header/Line
Validation
Reject
DOS Prior to 2012
Validation
Reject
Through DOS After Receipt Date
Validation
Reject
Verteporfin
Validation
Reject
Correct/Replace or Void ICN Not in EODS
Validation
Reject
Void Must Match Original
Pricing
Reject
Service(s) Not Covered Prior To 4/1/2013
Validation
Reject
Void Encounter Already Void/Adjusted
Validation
Reject
Adjusted Encounter Already Void/Adjusted
Validation
Reject
Billing Provider Different from Original
Validation
Reject
Unable to Void Rejected Encounter
Validation
Reject
Original Must Be Chart Review to Void
Validation
Reject
Original Must Be Chart Review to Adjust
Provider
Reject
Sanctioned Provider
Provider
Informational
Rendering Provider Not Eligible For DOS
Beneficiary
Informational
Invalid Beneficiary Last Name
Beneficiary
Reject
Beneficiary HICN Not On File
Beneficiary
Reject
DOS After Beneficiary DOD
Beneficiary
Reject
Beneficiary Gender Mismatch
Beneficiary
Reject
Beneficiary DOB Mismatch
Beneficiary
Reject
Beneficiary Not Enrolled In MAO For DOS
Beneficiary
Reject
Beneficiary Not Part A Eligible For DOS
Beneficiary
Reject
Beneficiary Not Part C Eligible For DOS
Validation
Reject
TOB Conflict With The Coverage Services
Pricing
Reject
Invalid CMG for IRF Encounter
Validation
Reject
CC 40 Required for Same Day Transfer
Validation
Reject
DOS Required for HH Encounter
Validation
Informational
Rev Code 091X Not Allowed
Validation
Reject
Rev Code 036X Requires Surgical CPT/HCPCS
Reference
Reject
RAP Not Allowed
Validation
Reject
Duplicate CPT/HCPCS and Unit Exceeds 1
Validation
Reject
Modifier Requires HCPCS Code
Validation
Reject
VC 05 Invalid with Rev Code
Validation
Reject
Modifier Not Within Effective Date
Reference
Informational
Age and Dx Code Conflict
Reference
Informational
Gender and Dx Code Conflict
Reference
Informational
Gender and CPT/HCPCS Conflict
Reference
Reject
ICD-9 Dx Code Error
Reference
Reject
ICD-9 CPT/HCPCS Error

837 Institutional Companion Guide Version 29.0/May 2014

TABLE 13 - ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS (CONTINUED)
EDIPPS
EDIPPS EDIT
EDIPPS EDIT
EDIPPS EDIT ERROR MESSAGE
EDIT#
CATEGORY
DESCRIPTION
18130
18135
18140
18145
18260
18265
18270
18500
18540
18705
18710
18730
18905
20035
20270
20450
20455
20500
20505
20510
20515
20520
20530
20835
20980
21925
21950
21951
21958
21976
21979
21980
21994
22015
22020
22095
22100
22135
22205
22220
22225

Reference
Reference
Reference
Reference
Reference
Reference
Validation
Conflict
Reference
Validation
Validation
Reference
Validation
Validation
Validation
Validation
Validation
Conflict
Conflict
Conflict
Conflict
Validation
Validation
Pricing
Pricing
Pricing
Pricing
Pricing
Pricing
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation

Reject
Reject
Reject
Reject
Reject
Informational
Informational
Informational
Informational
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Informational
Reject
Reject
Reject
Informational
Reject
Reject
Reject
Informational
Reject
Reject
Informational
Informational
Informational
Reject
Reject
Informational
Informational
Informational
Reject
Informational
Reject
Reject
Reject
Reject

Duplicate Principal Dx Code
Principal Dx Code is Manifestation Code
Principal Dx Code is E-Code
Unacceptable Dx Code
Invalid Rev Code
Dx Code V70.7 Required
Rev Code and HCPCS Required
Multiple CPT/HCPCS for Same Service
CPT/HCPCS Service Unit Out Of Range
Invalid Discharge Status
Missing/Invalid POA Indicator
Invalid Modifier Format
Age Is 0 Or Exceeds 124
Requires DOS for Rev Code 057X
From & Thru Dates Equal - Day Count > 1
Attending Physician is Sanctioned
Operating Provider Is Sanctioned
Invalid DOS for Rev Code Billed
Correct Ambulance HCPCS/Rev Code Required
Rev Code 054X Requires Specific HCPCS
Dx Code V053 Must Be Aligned With HCPCS
Invalid Ambulance Pick-up Location
Zip Cannot Be 0 or Blank
Service Line DOS Not Within Header DOS
Provider Cannot Bill TOB 12X or 22X
Swing Bed SNF Conditions Not Met
Line Level DOS Required
No OSC 70 or Covered Days Less Than 3
Rehab Therapy Ancillary Codes Required
OSC 70 Dates Outside of Coverage Period
Charges for Rev Code 0022 Must Be Zero
CC D2 Requires Change in One HIPPS
From Date Greater Than Admit Date
Number of Days Conflicts With HH Episode
Conflict Between CC and OSC
Encounter Must Be Submitted on 837-P DME
Rev Code 0023 Invalid for DOS
Multiple Rev Code 0023 Lines Present
Service Line Missing DOS
DOS Prior to Provider Effective Date
Missing Provider Specific Record

837 Institutional Companion Guide Version 29.0/May 2014

Validation
Validation
Validation
Validation
Validation
Validation
Validation
Pricing
Pricing
Validation
NCCI
Validation
Duplicate
Duplicate
Duplicate
10.1

Reject
Reject
Informational
Informational
Informational
Informational
Reject
Reject
Reject
Reject
Informational
Reject
Reject
Reject
Reject

Rev Code 277 Invalid for a HH
Service Line Requires DOS
HIPPS Code Required for SNF/HH
HIPPS Codes Conflicts with Revenue Code
HP Qualifier Must Exist for HIPPS Code
Occurrence Code 55 & DOD Required (DOS through 12/31/2012)
Occurrence Code 55 & DOD Required (DOS on or after 01/01/2013)
Invalid Service(s) for TOB
Revenue Code 0274 Required
TOB 33X Invalid for DOS
CCI Error
Height or Weight Value Exceeds Limit
Linked Chart Review Duplicate
Chart Review Duplicate
Service Line(s) Duplicated

EDIPPS Edits Enhancements Implementation Dates

As the EDS matures, the EDPS may require enhancements to the EDIPPS editing logic. As enhancements
occur, CMS will provide the updated information (i.e., disposition changes and activation or deactivation
of an edit). Table 14 provides MAOs and other entities with the implementation dates for
enhancements made to the EDIPPS since the last release of the CMS EDS 837-I Companion Guide.
Note: Table 14 will not be provided when there are no enhancements implemented for the current
release of the CMS EDS Companion Guides.
10.2

EDPS Edits Prevention and Resolution Strategies

In order to assist MAOs and other entities with the prevention of potential errors in their encounter
data submission and with resolution of edits received on the generated MAO-002 reports, CMS has
provided comprehensive strategies and scenarios. CMS has identified strategies and scenarios in three
(3) phases.
10.2.1 EDPS Edits Prevention and Resolution Strategies – Phase I: Frequently Generated EDIPPS Edits
Table 15 outlines Phase 1 of the prevention and resolution strategies for Institutional edits most
frequently generated on the MAO-002 reports.

837 Institutional Companion Guide Version 29.0/May 2014

TABLE 15 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE I

FREQUENTLY GENERATED EDIPPS EDITS
Edit
Comprehensive Resolution/Prevention
Disposition

Edit #

Edit Description

17310

Rev Code 036X Requires Surgical
CPT/HCPCS

Reject

Revenue Code 036X was submitted without required Surgical
CPT/HCPCS code. Provide appropriate CPT/HCPCS code
associated with this Revenue Code.
Scenario: Life and Health Associates submitted an encounter for Dr. Joshua Canterbury, who performed a prostate
cryosurgery on 5/15/2012. The encounter reported the Revenue Code of 036X, but did not include CPT code 55873.
17407 Modifier Requires HCPCS Code
Reject
Service line submitted with HCPCS modifier, but not the
required HCPCS code. Verify that codes/ modifiers are
accurate.
Scenario: Dr. Whitty submitted the HCPCS modifier code 25- Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the Day of a Procedure, without the appropriate level of E&M service.
17735 Modifier Not Within Effective
Reject
Modifier not active for DOS reported. Submitter must verify
Date
that modifiers reported are valid and current.
Scenario: As a follow up to a postoperative surgery on 8/1/2012, Dr. Whitty submitted HCPCS modifier code 21Prolonged evaluation and management services on 9/28/2012; however, the modifier was deactivated on 9/1/2012.
20035 Requires DOS for Rev Code 057X
Reject
Revenue Code 57X requires that DOS be reported on separate
service lines for each DOS. Ensure each service line for
Revenue Code 57X includes the appropriate DOS.
Scenario: Super Nurse Health submitted a claim to Grand Plan for five (5) nursing visits during the month of August.
Grand Plan submitted an encounter to the EDS with five (5) separate service lines all populated with “from” DOS of
8/2/2012 and “through” DOS of 8/30/2012. Grand Plan received an MAO-002 report with error message 20035 because
each service line requires a single “from” and “through” DOS.
20270 From & Thru Dates Equal - Day
Reject
Inpatient encounter contains same “from” and “through”
Count > 1
DOS; however, the day count reported in Loop 2320 MIA15
does not equal 1. Verify that DOS are accurate or that day
count is equal to 1.
Scenario: Nightline Hospital admitted a patient at 8 p.m. on 10/23/2012 and the patient was discharged at 2 p.m. on
10/24/2012. Dawn to Dusk Healthcare submitted the encounter with a day count of “2” for admission, although the
overnight stay is considered one (1) day.
20505 Correct Ambulance HCPCS/Rev
Reject
Revenue Code 540 populated without appropriate ambulance
Code Required
HCPCS codes and/or a unit greater than 1 for the HCPCS code.
Also provide HCPCS mileage codes.
Scenario: Blue Flight Health Plan submitted an encounter for ground ambulance services with Revenue Code 540;
however, the HCPCS code was not populated.
20510 Rev Code 054X Requires Specific
Reject
HCPCS code is not valid for submission with Revenue Code
HCPCS
540. Use an appropriate HCPCS code from the list of HCPCS
codes acceptable for submission with Revenue Code 540.
Scenario: Blue Flight Health Plan submitted a ground transportation ambulance Revenue Code 540 with a HCPCS code
A0021-Out of State Per Mile, which was valid for the service, but is invalid for Medicare.
20530 Zip Cannot Be 0 or Blank
Reject
Submitter must provide a valid nine (9)-digit ZIP code for
ambulance pick-up location.
Scenario: Mystery Health Plan submits an encounter on behalf of Rush Ambulance with an ambulance service line that
has the street address, city, state, and the ZIP code is indicated as “0”.

837 Institutional Companion Guide Version 29.0/May 2014

TABLE 15 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE I (CONTINUED)

Edit #
20835

Edit Description
Service Line DOS Not Within
Header DOS

FREQUENTLY GENERATED EDIPPS EDITS
Edit
Comprehensive Resolution/Prevention
Disposition
Reject

Line level DOS reported that does not fall within “from” and
“through” DOS range reported on header level of encounter.
Verify the accuracy of all DOS.
Scenario: Who Knows Hospital admitted Janet Doe on 6/1/2012 and discharged her on 6/10. Padre Care Plan submitted
an inpatient encounter on behalf of Who Knows Hospital for Ms. Doe. The service line DOS were correct; however, the
claim header indicated that Ms. Doe was admitted on 6/6/2012 and discharged on 6/12/2012.
10.2.2 EDPS Edits Prevention and Resolution Strategies – Phase II: Common EDPS Edits
Table 16 outlines Phase II for common edits generated in all subsystems of the EDPS (Professional,
Institutional, and DME).
TABLE 16 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II
COMMON EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
00010 From DOS Greater Than TCN
Reject
Encounter must have a DOS prior to submission date.
Date
Scenario: Perfect Health of America submitted an encounter to the EDS on May 10, 2012 for a knee replacement
performed at Wonderful Hills Mediplex for DOS May 12, 2012. The encounter was rejected because the “from” DOS was
after the date of encounter submission.
00011 Missing DOS in Header/Line
Reject
Encounter header and line levels must include “from” and
“through” DOS (procedure or service start date).
Scenario: Chloe Pooh was admitted to Regional Port Hospital on October 21, 2012 for a turbinectomy and was released
on October 22, 2012. Regional Port Hospital submitted a claim to Robbins Health for the surgical procedure. Robbins
Health submitted the encounter to the EDS, but did not include the “through” DOS of October 22, 2012.
00012 DOS Prior to 2012
Reject
Encounter must contain 2012 “through” DOS for each line.
Scenario: Ion Health submitted an encounter with DOS from December 2, 2011 through December 28, 2011, for an
inpatient admission at Better Health Hospital. EDS will only process encounters that include 2012 “through” DOS or later.
00025 Through DOS After Receipt Date
Reject
Encounter submitted with a service line “through” DOS that
occurred after the date the encounter was submitted.
Scenario: Leverage Community Health submitted an encounter on August 23, 2012 for a myringotomy performed by Dr.
Earwell. The service line DOS for the procedure was August 29, 2012. The encounter was rejected because the encounter
was submitted to the EDS before the DOS listed on the encounter.
00265 Correct/Replace or Void ICN Not
Reject
Adjustment/Void encounter submitted with an invalid ICN.
in EODS
Verify accuracy of ICN on the returned MAO-002 report.
Scenario: Chance Medical Services submitted an encounter to the EDS and received an MAO-002 report with an accepted
ICN of 123456789. The encounter required adjustment. Chance Medical Services submitted an adjustment encounter
using ICN 234567899. The adjustment encounter was rejected because there was no original record in the EDS for this
ICN with the same Submitter ID.

837 Institutional Companion Guide Version 29.0/May 2014

TABLE 16 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED)
COMMON EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
00699 Void Must Match Original
Reject
Voided encounter must have the same number of lines as the
original encounter.
Scenario: Lamb Professional Care submitted an encounter for an inpatient hospital stay with five (5) service lines. Lamb
Professional Care submitted a void encounter for the hospital stay. However, the void encounter contained only 4 lines
from the original encounter. Lamb Professional Care received an MAO-002 report with edit 00699 because one of the
lines from the original encounter was not included on the void encounter.
00761 Billing Provider Different from
Reject
Billing provider’s NPI must be identical in both the original
Original
and void encounters.
Scenario: Mastermind General Hospital submitted an encounter for a procedure performed by Dr. Jackson Martinez on
October 17, 2012. Spartacus Regional Health submitted the encounter to the EDS and received an MAO-002 report with
an accepted ICN of 342431098. On October 27, 2012, Spartacus Regional Health submitted a void encounter for ICN
342431098 using an NPI for Dr. Mary Jane. The encounter was rejected because the billing provider NPI on the void
encounter did not match the billing provider on the original encounter.
01405 Sanctioned Provider
Reject
CMS has suspended/terminated provider from performing
services for DOS submitted. Verify the accuracy of provider’s
NPI and DOS submitted.
Scenario: Dr. Domuch performed a cystectomy for Wally Dowright on October 2, 2012. Dr. Domuch submitted a claim to
Dermis Health Plan, who adjudicated the claim and submitted an encounter to the EDS. The EDS returned the encounter
to Dermis Health Plan with edit 01405 because Dr. Domuch’s privileges were suspended, effective August 29, 2012, for
one (1) year; therefore, Dr. Domuch was not authorized to perform this procedure.
01415 Rendering Provider Not Eligible
Informational Verify that NPI is accurate and that the provider was eligible
For DOS
for DOS submitted.
Scenario: ABC Care Plan submitted an encounter for a procedure performed by Dr. Destiny on February 14, 2012. The
EDPS provider reference files indicate that Dr. Destiny’s NPI was not effective until February 16, 2012.
02106 Invalid Beneficiary Last Name
Informational Verify that last name populated on the encounter matches
the last name listed in MARx database.
Scenario: Blue Skies Rural Health submitted an encounter for patient Ina Batiste-Rhogin. The MARx database listed the
patient as Ina Rhogin. The EDPS processed and accepted the encounter with an informational flag indicating that the
name provided on the encounter was not identical to the name listed in the eligibility database.
02110 Beneficiary HICN Not On File
Reject
Verify that HICN populated on the encounter is valid in MARx
database.
Scenario: Bright Medical Center submitted a claim to Sunshine Complete Health for an office visit for Mr. Everett Banks
for DOS May 26, 2012. Sunshine Complete Health submitted an encounter to the EDS. The EDS rejected the encounter
with edit 02110, because the HICN populated on the encounter was not on file in the MARx database.
02112 DOS After Beneficiary DOD
Reject
Verify that DOS submitted is accurate and does not exceed
the beneficiary DOD.
Scenario: Mountain Hill Health submitted an encounter for an inpatient admission for Ray Rayson for DOS July 15, 2012.
EDPS was unable to process the encounter because the MARx database indicated Mr. Rayson expired on July 13, 2012.
02120 Beneficiary Gender Mismatch
Reject
Verify that gender populated on the encounter is accurate
and matches gender listed in MARx database.
Scenario: Jenna Jorgineski went to Lollipop Lab for a sleep study on September 4, 2012. Lollipop Lab submitted a claim
for the sleep study to Capital City Community Care with Ms. Jorgineski’s gender identified as “male”. Capital City
Community Care submitted the encounter. The EDS processed and accepted the encounter. The MAO-002 report was
returned with an informational edit 02120, because Ms. Jorgineski’s gender was listed as “female” in the MARx database.

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TABLE 16 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED)
COMMON EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
02125 Beneficiary DOB Mismatch
Reject
Verify that DOB populated on the encounter is accurate and
matches DOB listed in MARx database.
Scenario: Swan Health submitted an encounter to the EDS for Joe Blough on March 3, 2012. The encounter listed Mr.
Blough’s DOB as December 13, 1940. The eligibility database (MARx) listed Mr. Blough’s DOB as December 13, 1937. The
EDS returned the MAO-002 report to Swan Health with edit 02125 due to the conflicting dates of birth.
02240 Beneficiary Not Enrolled In MAO
Reject
Verify that beneficiary was enrolled in your MAO during DOS
For DOS
on the encounter.
Scenario: Gabrielle Boyd was admitted to Faith Hospital for an appendectomy on June 11, 2012 and was discharged on
June 14, 2012. Faith Hospital submitted the claim for the hospital admission to Adams Healthcare. Adams Healthcare
adjudicated the claim and submitted an encounter to the EDS on July 12, 2012. Ms. Boyd’s effective date with Adams
Healthcare was July 1, 2011. The EDS returned an MAO-002 report to Adams Health with edit 02240 because Ms. Boyd
was not enrolled with the health plan for the DOS submitted by Faith Hospital.
02255 Beneficiary Not Part A Eligible
Reject
Verify that beneficiary was enrolled in Part A for DOS listed
For DOS
on the encounter.
Scenario: Mr. Carl Evergreen was transferred from a VA hospital and admitted to Rainforest Regional on April 28, 2012.
Mr. Evergreen was effective for Medicare Part A on May 1, 2012. Strides in Care Health Plan submitted the encounter for
the admission to Rainforest Regional and received an MAO-002 report with edit 02255 because Mr. Evergreen was
enrolled in Medicare Part A after the date of hospital admission.
02256 Beneficiary Not Part C Eligible
Reject
Verify that beneficiary was enrolled in Part C for DOS listed on
For DOS
the encounter.
Scenario: On July 4, 2012, Gail Williams has severe chest pains and goes to the emergency room for a chest x-ray at
Underwood Memorial Hospital. At the time of the emergency room visit, Ms. Williams only has Part A Medicare
coverage. Underwood Memorial submits the claim to AmeriHealth and the claim is adjudicated under Part A
Medicare. AmeriHealth submits an encounter to the EDS, which is rejected with edit 02256, because Ms. Williams is not
covered under Part C Medicare for the DOS.
25000 CCI Error
Informational Ensure CCI code pairs are appropriately used. Ensure that CCI
single codes meet the MUE allowable units of service (UOS).
Scenario: Hippos Health Plan submitted an encounter to the EDS with a DOS of May 5, 2012 and HCPCS code 15780 and
two (2) units of service. The returned MAO-002 report indicated an informational edit of 25000 because HCPCS code
15780 – dermabrasion, is only valid for one (1) unit of service per day.
98325 Service Line(s) Duplicated
Reject
Verify encounter was not previously submitted. If not a
duplicate encounter, ensure that elements validated by
duplicate logic are not the same (refer to the 2012 ED
Participant Guide for duplicate logic validation elements)
Scenario: Sanford Health Systems submitted an encounter for two (2) service lines for 15-minute therapy services. The
encounter lines submitted were the same for the timed procedure code, totaling 35 minutes and should have been
submitted with 2 units of service under the total time rather than as separate duplicate lines.
10.2.3 EDIPPS Edits Prevention and Resolution Strategies – Phase III: General EDIPPS Edits
Table 17 outlines Phase III for a portion of the remaining Institutional edits generated on the MAO-002
Encounter Data Processing Status Reports. Section 10.2.3 will be updated in future releases of the
Institutional Companion Guide until all remaining edits are identified.

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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
18010 Age and Dx Code Conflict
Informational Verify that diagnosis populated on the encounter is age
appropriate for beneficiary
Scenario: Clear Path Health submitted an encounter to the EDS for services provide to Mr. Jackson Leigh, who is 85-yrs old.
The diagnosis provided on the encounter was V20.2-routine child health check. The MAO-002 report returned contained
an informational edit of 18010 because the diagnosis provided was not appropriate for an 85-yr old.
18018 Gender and CPT/HCPCS Conflict Informational Gender provided for beneficiary does not agree with
procedure/service identified on the encounter. Verify gender
populated on encounter matches date in MARx. Ensure that
the procedure code is accurate and appropriate.
Scenario: Claims Health submitted an encounter for Jane Johnson with procedure code 58150-Total Hysterectomy.
However, the gender populated on the encounter identified Ms. Johnson as a male. The MAO-002 report was returned
with an informational error of 18018. CMS recommends that Claims Health verify the gender on Ms. Johnson’s HICN
information to ensure that it is corrected.
18135 Principal Dx is Manifestation
Reject
Encounter submitted using a code for underlying disease or
Code
symptom instead of a principal diagnosis. Ensure that
primary diagnosis is valid.
Scenario: Arbor Meadows Health submitted an encounter for an inpatient admission for Ms. Anabel Greaves. The
diagnosis submitted on the encounter was 3214-Meningitis due to sarcoidosis. The EDS rejected the encounter because
3214 is not a primary diagnosis, but is a manifestation code for a condition related to the diagnosis.
18260 Invalid Rev Code
Reject
Encounter submitted with a Revenue Code not related to
services provided or a Revenue Code not used.
Scenario: Home Sweet Home submitted a claim to Foundation Health for Home Health services provided to Ms. Jean.
Foundation Health submitted the encounter to the EDS using Revenue Code 0022. The encounter was rejected for edit
18260 because Foundation Health used a SNF revenue code for a Home Health encounter.
21980 CC D2 Requires Change in One
Reject
Adjustment encounter submitted with condition code D2;
HIPPS
however, the associated HIPPS code was not revised to
indicate the adjustment.
Scenario: Marxton Health sent an adjustment encounter to the EDS on behalf of Here For You Health, which contained
condition code of ‘D2” and an appropriate reason code to revise the HIPPs code originally submitted, but the HIPPS code
itself was not revised.
00755 Void Encounter Already
Reject
Submitter has previously voided or adjusted an encounter
Void/Adjusted
and is attempting to void the same encounter. Submitter
should review returned MAO-002 reports to confirm
processing of the voided encounter prior to resubmission of
the void.
Scenario: Happy Trails Health Plan submitted a void/delete encounter on October 10, 2012. Happy Trails Health Plan
voided the same encounter, in error, on October 15, 2012, prior to receiving the MAO-002 report for the initial void/delete
encounter, which was returned on October 16, 2012. The MAO-002 report for the subsequent voided encounter was
returned with edit 00755 due to the submission of the second void/delete encounter.

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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
00760 Adjusted Encounter Already
Reject
Submitter has previously adjusted or voided an encounter
Void/Adjusted
and is attempting to adjust the same encounter. Submitter
should review returned MAO-002 reports to confirm
processing of the adjusted encounter prior to resubmission of
the adjustment.
Scenario: On August 20, 2012, Pragmatic Health submitted a correct/replace encounter to correct a CPT code. Pragmatic
Health had not received their MAO-002 report by August 23, 2012 and decided to resubmit the correct/replace encounter.
The MAO-002 report was returned on August 24, 2012 with the correct/replace encounter identified as accepted.
Pragmatic Health received edit 00760 on the secondary MAO-002 report because the EDPS had already processed the
resubmitted correct/replace encounter.
00762 Unable to Void Rejected
Reject
Submitter is attempting to void a previously rejected
Encounter
encounter. Submitter should review returned MAO-002
reports to confirm the rejected encounter.
Scenario: On July 20, 2012, Hero Health Plan submitted an encounter with an invalid HICN. On July 26, 2012, Hero Health
Plan attempted to void the encounter due to the invalid HICN without referencing the MAO-002 report, dated July 25,
2012, that indicated that the encounter was rejected. On August 1, 2012, Hero Health Plan received an MAO-002 report
with edit 00762 for the voided encounter because the original encounter had already been processed and rejected.
02260 TOB Conflict With the Coverage
Reject
TOB populated on the encounter is not appropriate for the
Services
services identified
Scenario: WindSong Health Plan submitted an encounter to the EDS for Miss Big Mama’s admission to Lady of Love Skilled
Nursing Facility (SNF) populated with a type of bill (TOB) 32X. The encounter was rejected because TOB 32X is used for
Home Health Services.
17330 RAP Not Allowed
Reject
Adjustments are not allowed for Type of Bill 322 or 332
(Request for Anticipated Payment)
Scenario: Magic Morning Health Plan submitted an encounter to the EDS for BackHome Health (a primary HHA) with TOB
322. The encounter was rejected because the EDS does not accept Request for Anticipated Payment (RAP) encounters.
18012
Gender and Dx Code Conflict
Informational Encounter submitted with a beneficiary gender that does not
agree with the diagnosis populated on the encounter.
Scenario: Hindsight Health submitted an encounter for JuneBug Hospital for Mr. James Jewet with diagnosis code 641.1 –
Hemorrhage from placenta previa. The encounter was rejected because the diagnosis submitted is a female specific
diagnosis.
18130 Duplicate Principal Dx Code
Reject
Secondary diagnosis code submitted is a duplicate of the
primary diagnosis code.
Scenario: Solo Health Services submitted an encounter with a diagnosis code 413.9 in the ‘BK’ (primary diagnosis) and ‘BF’
(additional diagnosis) qualifier fields for the same service line. The encounter was rejected for duplicate primary
diagnoses.
18145 Unacceptable Dx Code
Reject
The diagnosis code populated on the encounter is invalid or
incorrectly populated.
Scenario: Hopewell Health Plan submitted an encounter to the EDS for Cornerstone Hospital for services provide to
Colonel Marcus on February 3, 2012. The diagnosis populated on the encounter was 518.5 – Pulmonary Insufficiency
Following Trauma or Surgery. The encounter was rejected for an unacceptable diagnosis because diagnosis code was
deleted and deemed invalid effective October 1, 2011.

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Edit #
21994

TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III
GENERAL EDPS EDITS
Edit
Edit Description
Comprehensive Resolution/Prevention
Disposition
From Date Greater Than Admit
Informational Encounter submitted with a 'from' date prior to the date of
Date
the beneficiary’s admission.

Scenario: Allison Oop was admitted to Mad Hatter Nursing Facility at 2:46 AM on April 1, 2012. Holiday Health submitted
the SNF encounter to the EDS with an admit date of April 1, 2012, but the service line from date was listed as March 29,
2012.
22220 DOS Prior to Provider Effective
Reject
Admission date indicated on encounter occurred before the
Date
provider’s NPI was deemed active/effective.
Scenario: Halo Home Health submitted an encounter to the EDS for Mr. Sweets’ admission on January 28, 2011 for DOS
February 1, 2012 through February 11, 2012 with NPI 0002220001. The encounter was rejected because the NPI effective
date was February 2, 2012, after the admission date.
00764 Original Must Be a Chart Review
Reject
Submitter must ensure that, if the void encounter (frequency
to Void
code ‘8’) is populated with PWK01=’09 and PWK02=’AA’, the
original encounter submission was a chart review encounter
populated with PWK01=’09’ and PWK02=’AA’. The submitter
must also ensure that the ICN references the initial chart
review encounter, not the original full encounter.
Scenario: On January 12, 2013, Paisley Community Health submitted an original encounter for Mr. Jolly Jones to the EDS
and received the accepted ICN of 3029683010582. On February 2, 2013, Paisley Community Health submitted a chart
review encounter to the EDPS to delete a diagnosis code from the original encounter and received the accepted ICN of
5039530285074. In April 2013, Paisley Community Health performed another chart review of Mr. Jones’ medical records
and discovered that the service was never provided. Paisley Community Health submitted a void encounter to the EDS
using the reference ICN of 3029683010582 (the original encounter ICN) and populated PWK01=’09’ and PWK02=’AA’. The
EDS rejected the encounter because the ICN referenced was for the original encounter, not the initial chart review.
00765 Original Must Be a Chart Review
Reject
Ensure that, if the correct/replace encounter (frequency code
to Adjust
‘7’) is populated with PWK01=’09 and PWK02=’AA’, the
original encounter submission was a chart review encounter
populated with PWK01=’09’ and PWK02=’AA’. The submitter
must also ensure that the ICN references the initial chart
review encounter, not the original full encounter.
Scenario: Flashback Health performed a chart review for Prosperous Living Medical Center. Flashback Health discovered
two (2) additional diagnosis codes for an encounter previously submitted for Ms. Leanne Liberty. Flashback Health
submitted an initial chart review encounter using the frequency code of ‘7’. The EDS rejected the chart review encounter
submission because initial chart review encounters should contain a frequency code ‘1’.
17404 Duplicate CPT/HCPCS and Unit
Reject
Encounter should not be submitted with a unit of greater
Exceeds 1
than 1 when any of the following HCPCS codes are provided
for a pap smear on a single DOS: Q0060, Q0061, P3000,
P3001, Q0091, G0123, G0124, G0143, G0144, G0145, G0147,
and G0148 nor can duplicate pap smear HCPCS Codes be
submitted for the same day.
Scenario: Dr. Michaels performed a pap smear on Miss Annabelle Lee prior to a gynecological procedure. The lab lost the
test sample. Dr. Michaels repeated the pap smear and performed the gynecological procedure. Group Health Plan
submitted the encounter for both of Miss Lee’s pap smears, using HCPCS code Q0060, and her surgical procedure. The
encounter was rejected because Medicare will not allow more than one (1) unit for Q0060 for a single service.

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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
18120 ICD-9 Dx Code Error
Reject
Submitter must ensure that the diagnosis codes populated on
an encounter are current and valid
Scenario: Mr. Jack Sprat was admitted to Mercy Me Hospital for an aortic endovascular graft placement. Mercy Me
Hospital submitted the claim for Mr. Sprat’s surgical services to Charity Health using diagnosis code 444.0 embolism and
thrombosis of abdominal aorta. Charity Health submitted the encounter and received edit 18120 because the diagnosis
code is no longer a valid ICD-9 CM code.
18140 Principal Dx Code is E-Code
Reject
Submitter must ensure that an e-code is submitted as a
subsequent diagnosis code. An E-code is never allowed as a
primary/principal diagnosis code and must not be populated
using the ‘BK’ qualifier
Scenario: Marney Gentos was admitted to Home Hospital for second degree burns. Fantasy Life Health Plan submitted
the encounter to the EDS and received an accepted ICN. Fantasy Life Health Plan later performed a chart review and
located an additional diagnosis code for services provided during Ms. Gentos’ stay at Home Hospital. Fantasy Life
submitted a chart review encounter to the EDS with a single diagnosis code of E9581 – Injury-burn, fire. The EDS rejected
the chart review submission because e-codes must never be submitted without a primary/principal diagnosis.
18905 Age Is 0 Or Exceeds 124
Reject
The age of the patient identified on the encounter must not
contain non-numeric values; or the age must not be
populated as 0 or greater than 124 years old
Scenario: Munali Mohair, a 27-yr old female was admitted to Petunia Mills General Hospital for an overnight stay due to
complications following an outpatient procedure. Petunia Mills submitted a claim to Flowery Lanes Health with Ms.
Mohair’s DOB listed as 09/23/1985. Flowery Lanes Health submitted the encounter to the EDS with Ms. Mohair’s DOB
listed as 09/23/1885, due to a typographical error. The EDS returned edit 18905 on the MAO-002 report.
20450 Attending Physician is
Reject
Submitter must ensure that the attending provider was not
Sanctioned
suspended or terminated from providing services to Medicare
beneficiaries during the time(s) of service indicated on the
encounter.
Scenario: Dr. Jernigan, attending physician at Hospice Hotel, made rounds on January 4, 2013, for fellow physician due to
an emergency. Hospice Hotel submitted Dr. Jernigan’s claim to Better Health. Better Health submitted the encounter to
the EDS. Dr. Jernigan’s privileges were terminated on December 20, 2012, and he was not authorized to provide services
for Hospice patients. Better Health received an MAO-002 report with a reject edit of 20450.
20455 Operating Provider Is
Informational Submitter must ensure that the operating provider was not
Sanctioned
suspended or terminated from providing surgical services to
Medicare beneficiaries during the time(s) of service indicated
on the encounter.
Scenario: Dr. Madhatter performed a cholecystectomy at Highway Hospital on March 12, 2013. Highway Hospital
submitted an Institutional claim to Providers Health Plan. Providers Health submitted the encounter to the EDS on May 6,
2013. It was discovered that Dr. Madhatter’s operating/surgical privileges were suspended on March 3, 2013. The EDS
returned the MAO-002 report to Providers Health with edit 20455.
20520 Invalid Ambulance Pick-up
Reject
Encounter for ambulance services must contain a valid ZIP
Location
code in Loop 2300 HI01-5 when Revenue Code 540 is used
with a Value Code of A0
Scenario: Family Health submitted an encounter for ambulance services provided by Monarch Medical Transport, but did
not populate the ambulance pick-up location because Monarch Medical Transport did not provide the ZIP code when
submitting the claim for services. The EDS rejected the encounter because the ambulance pick up location is a required
field on all ambulance encounters.
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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
27000 Height or Weight Value Exceeds
Reject
Encounters submitted with TOB 72X Values for A8 and A9
Limit
must be submitted in kilograms. For Value Code A8: Weight
must not exceed 318.2 Kg (700 lbs.). For Value Code A9:
Height must not exceed 228.6 Kg (7ft 6 in)
Scenario: Mr. Nestle Parks, a 432 lb. male, was admitted to Mountain Top Memorial Hospital with kidney failure due to
ESRD. River Run Health Plan submitted an encounter to the EDS for services provided to Mr. Parks during his stay at
Mountain Top Memorial. The encounter contained Mr. Parks’s weight in Loop 2300 HI Value Code A8 segment at 432.0.
The encounter was rejected with edit 27000 because the A8 value exceeded the allowable value of 318.2 kg. The
encounter should have been submitted with Mr. Parks weight identified as 196.36, because the EDS requires that the
measurements be populated in kilograms.
17257 Rev Code 091X Not Allowed
Informational Medicare no longer accepts Revenue Code 910 for
Psychiatric/Psychological Services. Ensure that the revenue
code submitted for psychiatric services is current and valid.
Scenario: Mr. Zane Zany was admitted to Far Side Institution due to severe depression. Way Out There Health Care
submitted an encounter on behalf of Far Side Institution populated with revenue code 0910, for services provided to Mr.
Zany during his admission from December 15, 2012 to January 14, 2013. The EDPS rejected the encounter submission
because, as of October 2003, revenue code 0910 was no longer a valid and acceptable Medicare revenue code.
18730 Invalid Modifier Format
Reject
Submitter must ensure that the modifier on the encounter is
acceptable and valid for EDS submission. Ensure that the
format is accurate and the appropriate characters are used.
Scenario: Pinky Marvelous was admitted to Check-In Memorial Hospital for a radical mastectomy of her left breast.
Check-In Memorial submitted a claim for the surgical procedure to Gallant Health Plan. Gallant Health Plan submitted the
encounter to the EDS, populated with CPT 19307, modifier ‘L6’. The EDPS rejected the encounter with edit 18730 because
the modifier was not entered accurately. The correct submission should be CPT 19307, modifier ‘LT’.
22015 Number of Days Conflicts With
Informational Submitter must ensure that the sum of the from and through
HH Episode
dates for the episode of care does not exceed 60 days
Scenario: Big Bell Home Health submitted a claim to Whamo Health Plan for Home Health services provided to Major
Colonel from February 3, 2013 through April 17, 2013. Whamo Health Plan submitted the encounter to the EDS with the
‘from’ and ‘through’ dates of February 3, 2013 through April 17, 2013 on one (1) service line. The encounter was rejected
because the episode of care exceeded the required maximum of 60 days.
22095 Encounter Must Be Submitted
Reject
If the NPI on the encounter identifies a DME Supplier, the
on 837-P DME
submitter must use the Payer ID of 80887 to indicate a the
service is for DMEPOS.
Scenario: Reach Rehab submitted an encounter for an electric hospital bed provided for Mr. Anton upon his discharge
from Meyers Medical Center. Reach Rehab Services submitted the encounter to the EDS using the Institutional payer ID of
80882.The encounter was rejected because, although Mr. Anton was discharged from the hospital and received care that
would be submitted on an Institutional encounter, services provided by Reach Rehab were specific to DMEPOS.
22135 Multiple Rev Code 0023 Lines
Reject
TOB 32X Home Health encounters must not contain more
Present
than one (1) service line containing revenue code 0023. Only
one (1) revenue code is defined for each prospective
payment system that requires HIPPS codes.
Scenario: Harmony Home Health submitted an encounter with two (2) service lines containing HIPPS codes HBFK2 and
HAEJ1. Harmony Home Health submitted separate revenue code 0023 service lines for each HIPPS code service line. The
EDS rejected the encounter because revenue code 0023 may not be used more than once on a single Home Health
encounter in conjunction with HIPPS codes.
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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
22225 Missing Provider Specific Record
Reject
Encounter was submitted that contains a provider NPI that is
not identified in the EDPS provider tables as a participating
Medicare provider.
Scenario: Ipse Institutional Hospital submitted an encounter file to the EDS for an inpatient procedure performed by Dr.
Wymee using NPI 0000000000. The EDPS rejected the encounter because Dr. Wymee was not identified in the EDS as a
participating Medicare provider.
22020 Conflict Between CC and OSC
Reject
Encounters submitted with condition code=C3 (Partial
Approval) must contain Occurrence Span Code (OSC) ‘MO’ to
indicate the service dates that were approved.
Scenario: Blue Bellman was admitted to The Best Nursing Facility on March 3, 2013 and discharged on April 26, 2013. The
Quality Improvement Organization (QIO) reviewed the claim submitted to Service Plus Health Plan by The Besting Nursing
Facility and denied service dates from April 3, 2013 through April 26, 2013. Service Plus Health Plan submitted the
approved dates of service (DOS) using condition code C3, but did not populate the encounter with the ‘MO’ modifier to
indicate that the March 3, 2013 through April 2, 2013 DOS were approved.
21951 No OSC 70 or Covered Days Less Informational Skilled Nursing Facility (SNF) encounters submitted using
Than 3
revenue code 0022 and TOB 21X, 22X, or 23X must include
the submission of Occurrence Span Code 70 to indicate the
dates of a qualifying hospital stay of at least three (3)
consecutive days, which qualifies the beneficiary for SNF
service.
Scenario: Stay With Us Nursing Care submitted a claim to Cornerstone Health Care for Mr. Bobst’s SNF stay from May 3,
2013 through May 13, 2013. Cornerstone Health Care submitted the encounter to the EDS using OSC 70; however, due to
a data entry error, the ‘from’ and ‘through’ dates on the encounter were May 3, 2013, indicating a one day service.
17085 CC 40 Required for Same Day
Reject
Encounters submitted with TOB 11X and a patient status code
Transfer
of 02, 03, 05, 50, 51, 61, 62, 63, 65, 66, or 70; and the
admission date is equal to the statement covers through date
must contain Condition Code 40.
Scenario: Wendy Wonder was admitted to Healthy Hospital on the morning of February 21, 2013 for a fall due to
hallucinations. Healthy Hospital transferred Ms. Wonder to their inpatient psychiatric unit on the evening of February 21,
2013. Health Hospital submitted Ms. Wonder’s claim to Wholeness Health using a patient status code of 65 (Discharged/
Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital) without providing the required Condition
Code 40. Wholeness Health adjudicated the claim and submitted the encounter to the EDS. The EDPS rejected the
encounter because inpatient hospital encounters populated with patient status code 65 must also contain Condition Code
40 to indicate that Ms. Wonder was admitted and discharged on the same date.
22280 Rev Code 277 Invalid for a HH
Reject
Home Health encounters cannot be submitted using revenue
code 277(Medical/surgical supplies oxygen (take home)).
Scenario: Fawn Home submitted a claim to Hulu Health Care for provision of oxygen to Cletus Clapp, using revenue cod
0023 for the home health service and revenue code 277 for the supply service. Hulu Health Care adjudicated the claim and
submitted the encounter to the EDS. Home Health received an MAO-002 report rejecting the encounter with edit 22280
because revenue code 277 is not a Medicare acceptable revenue code.

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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
18710 Missing/Invalid POA Indicator
Reject
Encounter type requires that an indicator of ‘Y’ or ‘N’ for
Present on Admission according to NUBC requirements, but
the indicator is not populated or is inaccurate for the data
provided in the encounter.
Scenario: Miss Ames was admitted to Hope Hospital for a stroke and a cerebral infarction with complications on March 26,
2013. She was discharged on April 5, 2013. Hope Hospital submitted a claim to Mount Vios for Miss Ames’ hospital
admission. Hope Hospital submitted an encounter to the EDS that did not include the required POA indicator of ‘Y’ due to
the diagnoses populated on the encounter. The EDS rejected the encounter with error code 18710.
21925 Swing Bed SNF Conditions Not
Reject
Encounter submitted with TOB 18X or 21X with Revenue
Met
Code 0022 and Occurrence Span Code 70 is not present or
Occurrence Code 50 is not present for each submission of
Revenue Code 0022.
Scenario: Riverwalk Rehab, a Skilled Nursing Facility, submitted a claim to Haven Health Care for Mr. Benson’s admission,
following his transfer after a ten (10) day stay at Marco General Hospital. Haven Health submitted an encounter to the EDS
using TOB 21X, Revenue Code 0022, and the required Occurrence Span Code of ‘70’, which indicated Mr. Bensons’
inpatient hospital stay of three (3) days or greater. The EDS rejected the encounter with error code 21925 because it did
not include the Occurrence Code of ‘50’, which is required for each service line submitted for Revenue Code 0022.
22405 Occurrence Code 55 & DOD
Reject
When patient discharge status code is 20 (expired), 40
Required
(expired at home), 41 (expired in a medical facility), or 42
(expired – place unknown), submitter must ensure that
Occurrence Code 55 and the date of death are present.
Scenario: Gentle HealthCare submitted a final claim to Monument Medical Health Plan for Mr. G. Barnes, who expired on
9/15/2013. Monument Medical Health submitted and encounter to the EDS with a patient discharge status code of 41 in
Loop 2300 CL103, but the Occurrence Code and Date of Death (occurrence code date) were not provided. The EDS
rejected the encounter on the MAO-002 Report with error code 22405.
17100 DOS Required for HH Encounter
Reject
Home Health encounters submitted with Revenue Codes 42X44X and 55X-59X must contain dates of service for the
revenue code line.
Scenario: Tympany Home Health submitted an encounter to the EDS for physical therapy services (Revenue Code 42X)
provided during a Home Health episode of care to Mrs. Waterman from August 3, 2013 to August 31, 2013. The encounter
was rejected with error code 17100 because, although the dates of service were populated on the encounter header level,
the revenue code line did not contain the physical therapy service dates.
00175 Verteporfin
Reject
Encounters submitted with TOB 13X or 85X for Ocular
Photodynamic Tomography with Verteporfin must
contain the same dates of service for the combination
of these services, with the appropriate ICD-9 and ICD10 diagnosis codes. Submitter must also ensure that
the procedures are valid for the dates of service.
Scenario: Dr. Cuff conducted an OPT with Verteporfin (J3396 and 67225) for Mr. Jay Bird as treatment for Mr. Bird’s
diagnosis of atrophic macular degeneration (362.51). The encounter was submitted to the EDS by Strideways Health and
rejected because the diagnosis of 362.51 should not be identified for the service submitted on the encounter.

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Edit #
00750

TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit Description
Comprehensive Resolution/Prevention
Disposition
Service(s) Not Covered Prior To
Reject
Encounters submitted for Ventricular Assist Devices (VADs)
4/1/2013
supplies/accessories with procedure code Q0507, Q0508, or
Q0509 must contain dates of service on or after 04/01/2013

Scenario: Dr. Zhivago’s office submitted a claim to Healthy Heart Health Plan for a battery and battery charger provided to
Mr. Joe Schmeaux following the attachment of his VAD on February 3, 2013. Healthy Heart submitted an encounter to the
EDS using Q0507. The EDS rejected the encounter with error code 00750 because Q0507 was not an effective code for
DOS prior to 4/1/2013.
22390 HIPPS Code Required for
Informational Encounters must contain HIPPS codes when submitted with
SNF/HH
TOB 18X or 21X and Revenue Code 0022 or TOB 32X and
Revenue Code 0023.
Scenario: Lamplight Home Health submitted an encounter to the EDS containing TOB 32X (Home Health – Inpatient),
Revenue Code 0023, and procedure code G0154(x2). The encounter did not contain a HIPPS code on the Revenue Code
0023 service line. The EDS returned the encounter with error code 22390, because all Home Health encounters must be
submitted with appropriate HIPPS codes.
22395 HIPPS Code Conflicts with
Informational Encounters must contain the appropriate HIPPS code for the
Revenue Code
service submitted. Revenue Code 0022 must contain
appropriate SNF HIPPS codes. Revenue Code 0023 must
contain appropriate HH HIPPS codes.
Scenario: Pink Lady Nursing Care submitted a claim to Aurelia Health Plan for SNF services provided for Ms. Jamella
Fantastic. Aurelia Health Plan submitted the encounter to the EDS with TOB 21X, Revenue Code 0022 and HIPPS code
HAEK2. The EDS returned the encounter with error code 22395, because the HIPPS code populated on the encounter
indicated a Home Health service instead of a Skilled Nursing Facility service.
22400 HP Qualifier Must Exist for HIPPS Informational Encounters submitted with TOB 18X or 21X and Revenue
Code
Code 0022 or TOB 32X and Revenue Code 0023 must contain
a value of ‘HP’ in the SV202-1 element for HIPPS codes.
Scenario: Serenity Care Nursing submitted a claim to Universal Medical Health Plan for Mr. Bacchus’ two (2) week stay at
their Skilled Nursing Facility. Universal Medical Health Plan submitted the encounter to the EDS with the appropriate
HIPPS codes; however, the qualifier was populated with ‘HC’ (procedure code qualifier).
22410 Invalid Service(s) for TOB
Reject
Encounters submitted for Ventricular Assist Devices (VADs)
supplies and accessories with procedure codes must only
contain specific bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X,
74X, or 85X). Note: TOB 33X is not applicable for DOS on or
after 10/1/2013
Scenario: Dr. Pandora submitted a claim to Healthy Heart Health Plan for wound care and dressings provided after Mr.
Jingleheimer’s pacemaker insertion. The encounter was submitted to the EDS with TOB 14X. The encounter was rejected
with error code 22410, because VAD supplies and accessories cannot be submitted with this bill type.
22415 Revenue code 0274 Required
Reject
Encounters submitted for Ventricular Assist Devices (VADs)
supplies/accessories with procedure code Q0507, Q0508, or
Q0509 must contain Revenue Code 0274 and the appropriate
bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, or 85X).
Scenario: Karma Health submitted an encounter to the EDS for VAD replacement leads using Revenue Code 0022. The
encounter was rejected with error code 22415 because Revenue Code 0274 is the only appropriate code for submission of
VAD supplies and accessories.

837 Institutional Companion Guide Version 29.0/May 2014

Edit #
22420

TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit Description
Comprehensive Resolution/Prevention
Disposition
TOB 33X Invalid for DOS
Reject
Encounters submitted with dates of service (DOS) on or after
10/01/2013 must not contain TOB 33X.

Scenario: Strong’s Home Care submitted an encounter with TOB 33X (Home Health – Outpatient) to the EDS for Home
Health services provided for Mr. V. Triumph from November 3, 2013 through November 18, 2013. The EDS rejected the
encounter and returned an MAO-002 report with error code 22420, because TOB 33X was deactivated for all DOS on or
after October 1, 2013.
18500 Multiple CPT/HCPCS for Same
Informational Encounters can not be submitted with multiple procedure
Service
codes to identify the same service/procedure.
Scenario: ProHealth submitted an encounter to the EDS with procedure code 15839 (labiaplasty) performed on Ms. Cross
on November 13, 2013. The EDS returned an MAO-002 report to ProHealth with error code 18500 because ProHealth had
already submitted another encounter for the same dates of service for Ms. Cross with procedure code 56620 (labiaplasty).
20500 Invalid DOS for Rev Code Billed
Reject
Encounter’s Revenue Code service date must be within the
range of the procedure service line DOS when submitting:
a)TOB 71X, 75X, or 77X with a valid Revenue Code; b)
Revenue Code 054X with TOBs 13X, 22X, 23X, 83X, or 85X; c)
Revenue Codes 042X, 43X, 044X, or 047X with TOBs 12X, 13X,
22X, 23X, 74X, or 83X; d) Revenue Code 047X with TOB 34X;
or e) Revenue Codes within the range of 0300-0319 with
HCPCS Codes 78267, 78268,80002-89399, or G0000-G9999
and TOBs 13X, 14X, 23X, 72X, 83X, or 85X
Scenario: Pink Acres Health Clinic submitted a claim to Way Out Health Plan for behavioral health services provided to
Cookie Triton from March 26, 2013 through April 12, 2013. Way Out Health Plan submitted an encounter to the EDS with
TOB 71X and Revenue Code 0900 with procedure service line DOS of March 26th – April 12th and Revenue Code service
dates of April 26th – May 12th. The EDS rejected the encounter because the Revenue Code service dates were not valid for
the dates of the service provided.
21979 Charges for Rev Code 0022 Must
Reject
For encounters submitted with TOB 18X or 21X and Revenue
Be Zero
Code 0022, the billed amount (Loop 2400 SV203) and noncovered charge amount (Loop 2400 SV207) should equal zero
when these fields are populated for the Revenue Code
service line.
Scenario: Mohair Nursing Camp submitted a claim to Fancy Free Health Plan for services provided to Curly Sue Skumptik.
Fancy Free Health Plan submitted an encounter for the services to the EDS containing a billed amount of $240.00 on the
Revenue Code 0022 service line. The EDS rejected the encounter and returned an MAO-002 Report containing error code
21979 because the Revenue Code service line billed amount and non-covered charge amounts must be either blank or
equal to zero.
98315 Linked Chart Review Duplicate
Reject
Linked Chart Review encounters cannot be submitted where
the HICN, Associated ICN, header DOS, diagnosis code(s) and
TOB contain the exact same values as another Chart Review
encounter already present within the EODS.
Scenario: Sequoia Health Plan conducted an audit of Langhorne Hospital and discovered an encounter previously
submitted to the EDS contained an unnecessary diagnosis code. On 04/01/2014, Sequoia Health Plan submitted a linked
chart review encounter to the EDS containing the associated ICN of the original encounter to identify the unnecessary
diagnosis code. On 05/01/2014 Sequoia Health Plan inadvertently submitted the exact same linked chart review encounter
to the EDS. The EDS rejected the second submission of the linked chart review encounter because no changes were
detected between the two linked chart review encounters.
837 Institutional Companion Guide Version 29.0/May 2014

TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
98320 Chart Review Duplicate
Reject
Unlinked Chart Review encounters cannot be submitted
where the HICN, header DOS, diagnosis code(s) and TOB
contain the exact same values as another Chart Review
encounter already present within the EODS.
Scenario: Ohio Health Plan conducted an audit of Cincinnati City Hospital and discovered an encounter not previously
submitted to the EDS required an additional diagnosis code. On 03/15/14, Ohio Health Plan submitted an unlinked chart
review encounter to the EDS to include the additional diagnosis code. On 06/01/14, Ohio Health Plan submitted the same
unlinked chart review encounter to the EDS due to a clerical error. The EDS rejected the second submission of the unlinked
chart review encounter because the EDS detected no changes between the two unlinked chart review encounters.
11.0

Submission of Default Data in a Limited Set of Circumstances

MAOs and other entities may submit default data in a limited set of circumstances, as identified and
explained in Table 18. MAOs and other entities cannot submit default data for any circumstances other
than those listed in the table below. CMS will use this interim approach for the submission of encounter
data. In each circumstance where default information is submitted, MAOs and other entities are
required to indicate in Loop 2300, NTE01=’ADD’, NTE02 = the reason for the use of default information.
If there are any questions regarding appropriate submission of default encounter data, MAOs and other
entities should contact CMS for clarification. CMS will provide additional guidance concerning default
data, as necessary.
11.1

Default Data Reason Codes (DDRC)

Loop 2300, NTE02 allows for a maximum of 80 characters and one (1) iteration, which limits the
submission of default data to one (1) message per encounter.
In order to allow the population of multiple default data messages in the NTE02 field, CMS will use a
three (3)-digit default data reason code (DDRC), which will map to the full default data message in the
EDS.
MAOs and other entities may submit multiple DDRCs with the appropriate three (3)-digit DDRC.
Multiple DDRCs will be populated in a stringed sequence with no spaces or separators between each
DDRC (i.e., 036040048). Table 18 provides the CMS approved situations for use of default data, the
default data message, and the default data reason code.

837 Institutional Companion Guide Version 29.0/May 2014

*DEFAULT DATA
Rejected Line Extraction
Medicaid Service Line Extraction
EDS Acceptable Anesthesia Modifier

TABLE 18 – DEFAULT DATA
DEFAULT DATA MESSAGE (NTE02)

DEFAULT DATA
REASON CODE

REJECTED LINES CLAIM CHANGE DUE TO REJECTED
LINE EXTRACTION
MEDICAID CLAIM CHANGE DUE TO MEDICAID SERVICE
LINE EXTRACTION
MODIFIER CLAIM CHANGE DUE TO EDS ACCEPTABLE
ANESTHESIA MODIFIER

036
040
044

Default NPI for atypical, paper, and 4010
claims

NO NPI ON PROVIDER CLAIM

048

Default EIN for atypical providers

NO EIN ON PROVIDER CLAIM

052

Chart Review Default Procedure Codes

DEFAULT PROCEDURE CODES INCLUDED IN CHART
REVIEW

056

True COB Default Adjudication Date

DEFAULT TRUE COB PAYMENT ADJUDICATION DATE

060

12.0

Tier II Testing

CMS developed the Tier II testing environment to ensure that MAOs and other entities have the
opportunity to test a more inclusive sampling of their data. MAOs and other entities that have obtained
end-to-end certification may submit Tier II testing data.
CMS encourages MAOs and other entities to utilize the Tier II testing environment when they have
questions or issues regarding edits received on EDFES Acknowledgement Reports or MAO-002
Encounter Data Processing Status reports; and when they have new submission scenarios that they wish
to test prior to submitting to production.
MAOs and other entities may submit chart review, correct/replace, or void/delete encounters to the
Tier II testing environment only when the encounters are linked to previously submitted and accepted
encounters in the Tier II testing environment.
Encounter files submitted to the Tier II testing environment must comply with the TR3, CMS Edits
Spreadsheet, and the CMS EDS Companion Guides, as well as the following requirements:
•
•
•
•
•
•

Files must be identified using the Authorization Information Qualifier data element “Additional
Data Identification” in the ISA segment (ISA01= 03).
Files must be identified using the Authorization Information data element to identify the “Tier II
indicator” in the ISA segment (ISA02= 8888888888).
Files must be identified as “Test” in the ISA segment (ISA15=T).
Submitters may send multiple Contract IDs per file
Submitters may send multiple files for a Contract ID, as long as each file does not exceed 2,000
encounters per Contract ID
If any Contract ID on a given file exceeds 2,000 encounters during the processing of the file, the
entire file will be returned

As with production encounter data, MAOs and other entities will receive the TA1, 999, and 277CA
Acknowledgement Reports and the MAO-002 Reports.
While not required, MAOs and other entities are strongly encouraged to correct errors identified on the
reports and resubmit data.
837 Institutional Companion Guide Version 29.0/May 2014

13.0

EDS Acronyms

Table 19 below outlines a list of acronyms that are currently used in EDS documentation, materials, and
reports distributed to MAOs and other entities. This list is not all-inclusive and should be considered a
living document; as acronyms will be added, as required.
TABLE 19 – EDS ACRONYMS

ACRONYM
A
ASC
C
CAH
CARC
CAS
CC
CCI
CCN
CEM
CMG
CMS
CORF
CPO
CPT
CRNA
CSC
CSCC
CSSC
D
DDRC
DME
DMEPOS
DMERC
DOB
DOD
DOS
E
E & M or E/M
EDDPPS
EDFES
EDI
EDIPPS
EDPPPS
EDPS
EDS
EIC
EODS
ESRD

DEFINITION
Ambulatory Surgery Center
Critical Access Hospital
Claim Adjustment Reason Code
Claim Adjustment Segments
Condition Code
Correct Coding Initiative
Claim Control Number
Common Edits and Enhancement Module
Case Mix Group
Centers for Medicare & Medicaid Services
Comprehensive Outpatient Rehabilitation Facility
Care Plan Oversight
Current Procedural Terminology
Certified Registered Nurse Anesthetist
Claim Status Code
Claim Status Category Code
Customer Service and Support Center
Default Data Reason Code
Durable Medical Equipment
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Durable Medical Equipment Carrier
Date of Birth
Date of Death
Date(s) of Service
Evaluation and Management
Encounter Data DME Processing and Pricing Sub-System
Encounter Data Front-End System
Electronic Data Interchange
Encounter Data Institutional Processing and Pricing Sub-System
Encounter Data Professional Processing and Pricing Sub-System
Encounter Data Processing System
Encounter Data System
Entity Identifier Code
Encounter Operational Data Store
End Stage Renal Disease

837 Institutional Companion Guide Version 29.0/May 2014

TABLE 19 – EDS ACRONYMS (CONTINUED)

ACRONYM
F
FFS
FQHC
FTP
FY
H
HCPCS
HHA
HICN
HIPAA
HIPPS
I
ICD-9CM/ICD-10CM
ICN
IPPS
IRF
M
MAC
MAO
MTP
MUE
N
NCD
NDC
NPI
NCCI
NOC
NPPES
O
OCE
OIG
OPPS
P
PACE
PHI
PIP
POA
POS
PPS

DEFINITION
Fee-for-Service
Federally Qualified Health Center
File Transfer Protocol
Fiscal Year
Healthcare Common Procedure Coding System
Home Health Agency
Health Information Claim Number
Health Insurance Portability and Accountability Act
Health Insurance Prospective Payment System
International Classification of Diseases, Clinical Modification (versions 9 and 10
Interchange Control Number
Inpatient Prospective Payment System
Inpatient Rehabilitation Facility
Medicare Administrative Contractor
Medicare Advantage Organization
Multiple Technical Procedure
Medically Unlikely Edits
National Coverage Determination
National Drug Codes
National Provider Identifier
National Correct Coding Initiative
Not Otherwise Classified
National Plan and Provider Enumeration System
Outpatient Code Editor
Officer of Inspector General
Outpatient Prospective Payment System
Program for All-Inclusive Care for the Elderly
Protected Health Information
Periodic Interim Payment
Present on Admission
Place of Service
Prospective Payment System

837 Institutional Companion Guide Version 29.0/May 2014

TABLE 19 – EDS ACRONYMS (CONTINUED)

ACRONYM
R
RAP
RHC
RNHCI
RPCH
S
SME
SNF
SSA
T
TARSC
TCN
TOB
TOS
TPS
V
VC
Z
ZIP Code

DEFINITION
Request for Anticipated Payment
Rural Health Clinic
Religious Nonmedical Health Care Institution
Regional Primary Care Hospital
Subject Matter Expert
Skilled Nursing Facility
Social Security Administration
Technical Assistance Registration Service Center
Transaction Control Number
Type of Bill
Type of Service
Third Party Submitter
Value Code
Zone Improvement Plan Code

837 Institutional Companion Guide Version 29.0/May 2014

REVISION HISTORY
DESCRIPTION OF REVISION

VERSION

DATE

2.1

9/9/2011

3.0

11/16/2011

Release 1

4.0

12/9/2011

Release 2

5.0

12/20/2011

Release 3

6.0

3/8/2012

Release 4

7.0

5/9/2012

Release 5

8.0

6/22/2012

Release 6

9.0

8/31/2012

Release 7

10.0

9/26/2012

Release 8

11.0

11/2/2012

Release 9

12.0

11/26/2012

Release 10

13.0

12/21/2012

Release 11

14.0

01/21/2013

Release 12

15.0

02/26/2013

Release 13

16.0

03/20/2013

Release 14

17.0

04/15/2013

Release 15

18.0

05/20/2013

Release 16

19.0

06/24/2013

Release 17

20.0

07/25/2013

Release 18

21.0

09/26/2013

Release 19

22.0

10/25/2013

Release 20

23.0

11/22/2013

Release 21

24.0

12/27/2013

Release 22

25.0

01/20/2014

Release 23

26.0

02/21/2014

Release 24

27.0

03/18/2014

Release 25

Baseline Version

837 Institutional Companion Guide Version 29.0/May 2014

REVISION HISTORY (CONTINUED)
DESCRIPTION OF REVISION

VERSION

DATE

28.0

04/28/2014

Release 26

29.0

05/30/2014

Section 13.0, Table 19 – Updated EDS Acronyms table

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1152. The time
required to complete this information collection is not applicable (N/A). If you have any comments concerning the
accuracy of the time estimate(s) or suggestions on improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

837 Institutional Companion Guide Version 29.0/May 2014

File Type	application/pdf
File Title	Companion Guide - Instituitional Transaction
Author	andreab
File Modified	2017-08-28
File Created	2014-06-02