The six dispositions
Each edit has one disposition, and the disposition, not the edit, decides what the hospital can do next: fix and resubmit, appeal, or wait. A claim can carry edits with several dispositions at once.
| Disposition | Code | What it means for the claim | Edits in effect |
|---|---|---|---|
| Claim Rejection | CR | The whole claim is rejected. Correct and resubmit it; a rejection cannot be appealed. | 1 of 1 |
| Claim Denial | CD | The whole claim is denied. It cannot be resubmitted, but the denial can be appealed. | 0 of 1 |
| Return to Provider | RTP | The claim comes back before adjudication (no remittance advice). Fix the flagged item and resubmit. | 63 of 84 |
| Suspension | SUS | The claim is held, not returned, until the MAC reviews it or obtains more information. | 7 of 13 |
| Line Item Rejection | LIR | The claim is paid without the rejected line. The line can be corrected and resubmitted but not appealed. | 28 of 31 |
| Line Item Denial | LID | The claim is paid without the denied line. The line cannot be resubmitted but can be appealed. | 12 of 15 |
Return to provider is the most common disposition, used for problems the hospital can fix on its own: an invalid diagnosis, procedure, revenue code, modifier or date, or a code reported on a bill type that cannot carry it. Because a returned claim never reaches adjudication, there is no 835 and no reason code; the fix happens in the contractor's claim correction screens or through a corrected submission. Line item rejections and denials do reach the remittance, as line-level adjustments, and they need different responses: a rejected line is corrected and resubmitted, a denied line is appealed with documentation.
Common edits and the matching denial codes
The I/OCE returns edit numbers to the contractor; it does not choose the codes on the remittance advice. The contractor's claims system translates line rejections and denials into claim adjustment reason codes (CARC) and remittance advice remark codes (RARC). The table matches the most frequent edits to the codes whose X12 definitions describe the same problem, so a denial team can move from the code on the 835 to the edit and back. Use the codes on your own remittance when they differ.
| Edit | Edit name | Disposition | Matching codes | Why |
|---|---|---|---|---|
| 9 | Non-covered under any Medicare outpatient benefit for reasons other than statutory exclusion | LID (line item denial) | CARC 96 | The line is non-covered; CARC 96 is the non-covered charge reason. |
| 17 | Inappropriate specification of bilateral procedure | LIR (line item rejection) | CARC 4 | A bilateral procedure reported in a way the modifier rules do not allow; CARC 4 covers a missing or inconsistent modifier. |
| 18 | Inpatient procedure | LID (line item denial) | CARC 5 | An inpatient-only (status C) procedure on an outpatient bill: the procedure does not fit the type of bill. |
| 20 | Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is present | LIR (line item rejection) | CARC 236, CARC 97, RARC M15 | NCCI pair with modifier indicator 0: CARC 236 names NCCI; CARC 97 with M15 is the bundled-service form. |
| 40 | Code2 of a code pair that would be allowed by NCCI if appropriate modifier were present | LIR (line item rejection) | CARC 236, CARC 97, RARC M15 | NCCI pair with modifier indicator 1 and no qualifying modifier on the line. |
| 47 | Service is not separately payable | LIR (line item rejection) | CARC 234, CARC 97 | Only packaged services on the claim: nothing is paid separately. |
| 49 | Service on same day as inpatient procedure | LID (line item denial) | CARC 97, RARC M80 | Services on the same day as an inpatient-only procedure are denied with it. |
| 68 | Service provided prior to date of National Coverage Determination (NCD) or Demonstration approval | LID (line item denial) | CARC 50, RARC N386 | Service dated before the National Coverage Determination that allows it. |
| 83 | Service provided on or after effective date of NCD | LID (line item denial) | CARC 50, RARC N386 | Service dated on or after an NCD that ends or limits its coverage. |
| 106 | Add-on code reported without required primary procedure code | LID (line item denial) | CARC 107, RARC N122 | Type 1 add-on code without one of its listed primary codes on the claim. On a standard OPPS claim (013x) only remote mental health and software-as-a-service add-ons are edited. |
| 107 | Add-on code reported without required contractor-defined primary procedure code | LID (line item denial) | CARC 107, RARC N122 | Type 2 add-on code without a primary code the contractor accepts, on a critical access hospital professional line (085x, revenue code 096x-098x). |
| 108 | Add-on code reported without required primary procedure or required contractor-defined primary procedure code | LID (line item denial) | CARC 107, RARC N122 | Type 3 add-on code without a listed or contractor-accepted primary code, on the bill types the specification lists, not a standard OPPS 013x claim. |
How the I/OCE carries the NCCI edits
The I/OCE applies the National Correct Coding Initiative to outpatient facility claims. The hospital procedure-to-procedure table becomes edits 20 and 40: the column-two code of a pair is rejected, with edit 20 when the pair allows no modifier and edit 40 when it allows one but the line does not carry it. Both are line item rejections, so the remedy is to correct the line, by removing the column-two code or by adding a modifier the record supports, and resubmit. With the hospital outpatient table selected, the NCCI pair checker shows which code of a pair is column two and whether a modifier can apply. The add-on code edits become edits 106, 107 and 108, one per edit type, as line item denials on the bill types the specification lists; edit 107 is returned only on critical access hospital (085x) professional lines. On a standard OPPS hospital outpatient claim (013x) only edit 106 applies, and only to remote mental health and software-as-a-service add-on codes. The add-on code reference explains the types. Unit limits are not I/OCE edits: the contractor applies the outpatient hospital MUE table separately, and the MUE lookup shows the value for any code.
All 145 edits by claim area
The I/OCE files each edit under the part of the claim it examines. Status shows whether the edit is in effect for current dates of service and whether the specification lists it for a standard hospital outpatient claim (bill type 013x without a program condition code) or only for specific bill types and programs, such as partial hospitalization and intensive outpatient claims, rural health clinics, federally qualified health centers or community mental health centers. On a 013x claim edit 106 applies only to remote mental health and software-as-a-service add-on codes, so its status reads "In effect, 013x for specific codes". A retired edit can still apply to a claim whose service dates fall before the edit ended, as long as those dates are inside the seven-year window of logic the software keeps.
Claim edits (5, 5 in effect)
Edits about the claim as a whole: bill type, receipt date and the program a partial hospitalization or intensive outpatient claim belongs to.
| Edit | Edit name (CMS) | Disposition | Status | Denial codes |
|---|---|---|---|---|
| 24 | Date out of OCE range | SUS (suspension) | In effect, 013x | — |
| 118 | Invalid bill type | RTP (return to provider) | In effect, specific bill types | — |
| 119 | Invalid claims processing receipt date | RTP (return to provider) | In effect, 013x | — |
| 190 | IOP Primary service not reported for IOP claim | RTP (return to provider) | In effect, specific bill types | — |
| 191 | PHP Primary service not reported for PHP claim | RTP (return to provider) | In effect, specific bill types | — |
Diagnosis edits (6, 5 in effect)
Edits about the diagnosis codes: validity, age, and codes that cannot be the principal diagnosis.
| Edit | Edit name (CMS) | Disposition | Status | Denial codes |
|---|---|---|---|---|
| 1 | Invalid diagnosis code | RTP (return to provider) | In effect, 013x | — |
| 2 | Diagnosis and age conflict | RTP (return to provider) | In effect, 013x | — |
| 3 | Diagnosis and sex conflict | RTP (return to provider) | Retired | — |
| 5 | External cause of morbidity code cannot be used as principal diagnosis | RTP (return to provider) | In effect, 013x | — |
| 86 | Manifestation code not allowed as principal diagnosis | RTP (return to provider) | In effect, 013x | — |
| 113 | Supplementary or additional code not allowed as principal diagnosis | RTP (return to provider) | In effect, 013x | — |
Procedure edits (122, 91 in effect)
Edits about the HCPCS and CPT lines: validity, coverage flags, code pairs, add-on codes, devices, observation, partial hospitalization and program rules.
| Edit | Edit name (CMS) | Disposition | Status | Denial codes |
|---|---|---|---|---|
| 4 | Medicare secondary payer alert | SUS (suspension) | Retired | — |
| 6 | Invalid procedure code | RTP (return to provider) | In effect, 013x | — |
| 7 | Procedure and age conflict | LIR (line item rejection) | In effect, 013x | — |
| 8 | Procedure and sex conflict | RTP (return to provider) | Retired | — |
| 10 | Service submitted for denial | CD (claim denial) | Retired | — |
| 11 | Service submitted for MAC review | SUS (suspension) | In effect, 013x | — |
| 12 | Questionable covered service | SUS (suspension) | In effect, 013x | — |
| 13 | Separate payment for services is not provided by Medicare | LIR (line item rejection) | In effect, 013x | — |
| 14 | Code indicates a site of service not included in OPPS | RTP (return to provider) | Retired | — |
| 15 | Service unit out of range for procedure (inactive) | RTP (return to provider) | Retired | — |
| 16 | Multiple bilateral procedures without modifier 50 | RTP (return to provider) | Retired | — |
| 17 | Inappropriate specification of bilateral procedure | LIR (line item rejection) | In effect, 013x | CARC 4 |
| 18 | Inpatient procedure | LID (line item denial) | In effect, 013x | CARC 5 |
| 19 | Mutually exclusive procedure that is not allowed by NCCI even if appropriate modifier is present | LIR (line item rejection) | Retired | — |
| 20 | Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is present | LIR (line item rejection) | In effect, 013x | CARC 236, CARC 97, RARC M15 |
| 21 | Medical visit on the same day as a type T or S procedure without modifier 25 | RTP (return to provider) | In effect, 013x | — |
| 25 | Invalid age | RTP (return to provider) | In effect, 013x | — |
| 26 | Invalid sex | RTP (return to provider) | In effect, 013x | — |
| 27 | Only incidental services reported | CR (claim rejection) | In effect, 013x | — |
| 28 | Code not recognized by Medicare for outpatient claims; alternate code for same service may be available | LIR (line item rejection) | In effect, 013x | — |
| 29 | PHP/IOP service for non-mental health diagnosis | RTP (return to provider) | In effect, specific bill types | — |
| 30 | Insufficient services on day of partial hospitalization (inactive) | LID (line item denial) | Retired | — |
| 31 | Partial hospitalization on same day as ECT or type T procedure | SUS (suspension) | Retired | — |
| 32 | Partial hospitalization claim spans 3 or less days with insufficient services on at least one of the days | SUS (suspension) | Retired | — |
| 33 | Partial hospitalization claim spans more than 3 days with insufficient number of days having mental health services | SUS (suspension) | Retired | — |
| 34 | Partial hospitalization claim spans more than 3 days with insufficient number of days meeting partial hospitalization criteria | SUS (suspension) | Retired | — |
| 35 | Only Mental Health education and training services provided | RTP (return to provider) | In effect, 013x | — |
| 36 | Extensive mental health services provided on day of type T procedure | SUS (suspension) | Retired | — |
| 37 | Terminated bilateral procedure or terminated procedure with units greater than one | RTP (return to provider) | In effect, 013x | — |
| 38 | Inconsistency between implanted device or administered substance and implantation or associated procedure | RTP (return to provider) | In effect, 013x | — |
| 39 | Mutually exclusive procedure that would be allowed by NCCI if appropriate modifier were present (combined with edit 40 retroactive to earliest included version) | LIR (line item rejection) | Retired | — |
| 40 | Code2 of a code pair that would be allowed by NCCI if appropriate modifier were present | LIR (line item rejection) | In effect, 013x | CARC 236, CARC 97, RARC M15 |
| 42 | Multiple medical visits on same day with same revenue code without condition code G0 | RTP (return to provider) | In effect, 013x | — |
| 43 | Transfusion or blood product exchange without specification of blood product | RTP (return to provider) | In effect, 013x | — |
| 44 | Observation revenue code on line item with non-observation HCPCS code | RTP (return to provider) | In effect, 013x | — |
| 45 | Inpatient separate procedures not paid | LIR (line item rejection) | In effect, 013x | — |
| 46 | Partial hospitalization condition code 41 not approved for type of bill | RTP (return to provider) | In effect, specific bill types | — |
| 47 | Service is not separately payable | LIR (line item rejection) | In effect, 013x | CARC 234, CARC 97 |
| 49 | Service on same day as inpatient procedure | LID (line item denial) | In effect, 013x | CARC 97, RARC M80 |
| 51 | Observation code G0378 not allowed to be reported more than once per claim | RTP (return to provider) | In effect, 013x | — |
| 52 | Observation does not meet minimum hours, qualifying diagnoses, and/or "T" procedure conditions | RTP (return to provider) | Retired | — |
| 53 | Codes G0378 and G0379 only allowed with bill type 13x or 85x | LIR (line item rejection) | In effect, specific bill types | — |
| 54 | Multiple codes for the same service | RTP (return to provider) | Retired | — |
| 55 | Non-reportable for site of service | RTP (return to provider) | In effect, specific bill types | — |
| 56 | E/M condition not met and line item date for obs code G0378 is not 12/31/ or 1/1 | RTP (return to provider) | Retired | — |
| 57 | E/M condition not met for observation and line item date for code G0378 is 1/1 | SUS (suspension) | In effect, 013x | — |
| 58 | Direct admittance G0379 only allowed with obervation G0378 | RTP (return to provider) | In effect, 013x | — |
| 59 | Clinical trial requires diagnosis code V707 as other than primary diagnosis (deleted retroactive to the earliest included version) | RTP (return to provider) | Retired | — |
| 60 | Use of modifier CA with more than one procedure not allowed | RTP (return to provider) | In effect, 013x | — |
| 61 | Service can only be billed to the DMERC | RTP (return to provider) | In effect, 013x | — |
| 62 | Code not recognized by OPPS; alternate code for same service may be available | RTP (return to provider) | In effect, 013x | — |
| 63 | Occupational therapy service only billable on partial hospitalization claims | RTP (return to provider) | Retired | — |
| 64 | Activity therapy service not payable outside the partial hospitalization program | LIR (line item rejection) | Retired | — |
| 66 | Code requires manual pricing | SUS (suspension) | In effect, 013x | — |
| 67 | Service provided prior to FDA approval | LID (line item denial) | In effect, 013x | — |
| 68 | Service provided prior to date of National Coverage Determination (NCD) or Demonstration approval | LID (line item denial) | In effect, 013x | CARC 50, RARC N386 |
| 69 | Service provided outside approval period | LID (line item denial) | In effect, 013x | — |
| 70 | CA modifier requires patient discharge status indicating expired or transferred | RTP (return to provider) | In effect, 013x | — |
| 71 | Claim lacks required device code | RTP (return to provider) | Retired | — |
| 72 | Service not billable to the Medicare Administrative Contractor | RTP (return to provider) | In effect, 013x | — |
| 73 | Incorrect billing of blood and blood products | RTP (return to provider) | In effect, 013x | — |
| 74 | Units greater than one for bilateral procedure billed with modifier 50 | RTP (return to provider) | In effect, 013x | — |
| 76 | Trauma response critical care code without revenue code 068x and CPT 99291 | LIR (line item rejection) | In effect, 013x | — |
| 77 | Claim lacks allowed procedure code | RTP (return to provider) | Retired | — |
| 78 | Claim lacks required radiolabeled product | RTP (return to provider) | Retired | — |
| 79 | Incorrect billing of revenue code with HCPCS code | RTP (return to provider) | In effect, 013x | — |
| 80 | Mental health code not approved for partial hospitalization | RTP (return to provider) | In effect, specific bill types | — |
| 81 | Mental health service not payable outside the partial hospitalization program | RTP (return to provider) | In effect, 013x | — |
| 82 | Charge exceeds token charge ($1.00) | RTP (return to provider) | In effect, 013x | — |
| 83 | Service provided on or after effective date of NCD | LID (line item denial) | In effect, 013x | CARC 50, RARC N386 |
| 84 | Claim lacks required primary code | RTP (return to provider) | Retired | — |
| 85 | Claim lacks required device code or required procedure code | RTP (return to provider) | Retired | — |
| 87 | Skin substitute application procedure without appropriate skin substitute product code | RTP (return to provider) | In effect, 013x | — |
| 88 | FQHC payment code not reported for FQHC claim | RTP (return to provider) | In effect, specific bill types | — |
| 89 | FQHC claim lacks required qualifying visit code | RTP (return to provider) | In effect, specific bill types | — |
| 91 | Item or service not covered under FQHC PPS or for RHC | LIR (line item rejection) | In effect, specific bill types | — |
| 92 | Device-intensive procedure reported without device code | RTP (return to provider) | In effect, 013x | — |
| 93 | Corneal tissue processing reported without cornea transplant procedure | LIR (line item rejection) | In effect, 013x | — |
| 94 | Biosimilar HCPCS reported without biosimilar modifier | RTP (return to provider) | Retired | — |
| 95 | 7-day spanning partial hospitalization services require a minimum of 20 hours of service as evidenced in PHP plan of care | LIR (line item rejection) | In effect, specific bill types | — |
| 96 | Partial hospitalization interim claim from and through dates must span more than 4 days | RTP (return to provider) | Retired | — |
| 97 | Partial hospitalization services are required to be billed weekly | RTP (return to provider) | Retired | — |
| 98 | Claim with pass through device or device with payment limitation lacks required procedure | RTP (return to provider) | In effect, 013x | — |
| 99 | Claim with pass-through or non-pass-through drug or biological lacks OPPS payable procedure | RTP (return to provider) | In effect, 013x | — |
| 100 | Claim for HSCT allogeneic transplantation lacks required revenue code line for donor acquisition services | RTP (return to provider) | In effect, 013x | — |
| 101 | Item or service with modifier PN not allowed under PFS | RTP (return to provider) | In effect, 013x | — |
| 102 | Modifier pairing not allowed on the same line | RTP (return to provider) | In effect, 013x | — |
| 104 | Service not eligible for all-inclusive rate | LIR (line item rejection) | In effect, specific bill types | — |
| 105 | Claim reported with pass-through device prior to FDA approval for the procedure | LID (line item denial) | In effect, 013x | — |
| 106 | Add-on code reported without required primary procedure code | LID (line item denial) | In effect, 013x for specific codes | CARC 107, RARC N122 |
| 107 | Add-on code reported without required contractor-defined primary procedure code | LID (line item denial) | In effect, specific bill types | CARC 107, RARC N122 |
| 108 | Add-on code reported without required primary procedure or required contractor-defined primary procedure code | LID (line item denial) | In effect, specific bill types | CARC 107, RARC N122 |
| 109 | Code first diagnosis present without mental health diagnosis as the first secondary diagnosis | RTP (return to provider) | In effect, specific bill types | — |
| 110 | Service provided prior to initial marketing date | LIR (line item rejection) | In effect, 013x | — |
| 111 | Service cost is duplicative; included in cost of associated biological | LIR (line item rejection) | In effect, 013x | — |
| 112 | Information-Only Service | LIR (line item rejection) | In effect, 013x | — |
| 114 | Item or service not allowed with modifier CS | RTP (return to provider) | Retired | — |
| 115 | COVID-19 lab add-on code reported without required primary procedure | LID (line item denial) | Retired | — |
| 116 | Opioid treatment program service not payable outside the opioid treatment program | RTP (return to provider) | In effect, 013x | — |
| 117 | Token charge less than $1.01 billed by provider | LIR (line item rejection) | In effect, 013x | — |
| 120 | Incorrect reporting of modifier PT | RTP (return to provider) | In effect, 013x | — |
| 121 | Non-covered service reported with inpatient only procedure where the patient expired or transferred | LID (line item denial) | In effect, 013x | — |
| 122 | 340B-acquired drug modifier(s) reported inappropriately | RTP (return to provider) | Retired | — |
| 124 | HCPCS reported after CMS termination date | RTP (return to provider) | In effect, 013x | — |
| 125 | Incorrect billing of IMRT planning and delivery | RTP (return to provider) | In effect, 013x | — |
| 126 | Incorrect reporting of telehealth modifier | RTP (return to provider) | In effect, specific bill types | — |
| 128 | Insufficient services on day of IOP | LIR (line item rejection) | In effect, specific bill types | — |
| 129 | Weekly IOP services require a minimum of 9 hours of service | LIR (line item rejection) | In effect, specific bill types | — |
| 130 | Incorrect reporting of modifier on RHC IOP claim | RTP (return to provider) | In effect, specific bill types | — |
| 131 | Insufficient services on day of PHP | LIR (line item rejection) | In effect, specific bill types | — |
| 132 | Mental health code not approved for Intensive Outpatient Program | RTP (return to provider) | In effect, specific bill types | — |
| 133 | Mental health service not payable outside the Intensive Outpatient program | RTP (return to provider) | In effect, 013x | — |
| 134 | Service provided outside designated approval period | LIR (line item rejection) | In effect, 013x | — |
| 135 | Claim Day lacks required device code | RTP (return to provider) | In effect, 013x | — |
| 136 | Service provided prior to ACIP approval date | LIR (line item rejection) | In effect, 013x | — |
| 137 | More than 2 non-opioid pain relief devices reported | LIR (line item rejection) | In effect, 013x | — |
| 138 | More than 3 non-opioid surgical pain drugs reported | LIR (line item rejection) | In effect, 013x | — |
| 139 | Telehealth service reported incorrectly with modifier 93 or 95 | RTP (return to provider) | In effect, 013x | — |
| 140 | Non-BLA skin substitute product reported incorrectly with modifier JW or JZ | RTP (return to provider) | In effect, 013x | — |
| 141 | HCPCS reported on or after mid-quarter effective date with bypassed or converted SI and/or APC | LIR (line item rejection) | In effect, 013x | — |
| 192 | Multiple occurrences of the same Payer Value Code present; MAC to use a different Payer Only modifier on the line(s) that caused the claim to suspend which produces the next available Payer Value Code | SUS (suspension) | In effect, 013x | — |
| 193 | HCPCS present with a Payer Only modifier for contractor bypass without MAC-provided Payer Value Code Z7 and Value Code amount | SUS (suspension) | In effect, 013x | — |
Modifier edits (4, 2 in effect)
Edits about the modifiers on a line: validity, pairing and dates.
| Edit | Edit name (CMS) | Disposition | Status | Denial codes |
|---|---|---|---|---|
| 22 | Invalid modifier | RTP (return to provider) | In effect, 013x | — |
| 75 | Incorrect billing of modifier FB or FC | RTP (return to provider) | Retired | — |
| 103 | Modifier reported prior to FDA approval date | LID (line item denial) | Retired | — |
| 123 | Modifier used after CMS termination date | RTP (return to provider) | In effect, 013x | — |
Date edits (1, 1 in effect)
Edits about the service dates on the claim.
| Edit | Edit name (CMS) | Disposition | Status | Denial codes |
|---|---|---|---|---|
| 23 | Invalid date | RTP (return to provider) | In effect, 013x | — |
Revenue Center edits (7, 7 in effect)
Edits about revenue codes: validity, a missing HCPCS where one is required, and coverage.
| Edit | Edit name (CMS) | Disposition | Status | Denial codes |
|---|---|---|---|---|
| 9 | Non-covered under any Medicare outpatient benefit for reasons other than statutory exclusion | LID (line item denial) | In effect, 013x | CARC 96 |
| 41 | Invalid revenue code | RTP (return to provider) | In effect, 013x | — |
| 48 | Revenue center requires HCPCS | RTP (return to provider) | In effect, 013x | — |
| 50 | Non-covered under any Medicare outpatient benefit | RTP (return to provider) | In effect, 013x | — |
| 65 | Revenue code not recognized by Medicare | LIR (line item rejection) | In effect, 013x | — |
| 90 | Incorrect revenue code reported for FQHC payment code | RTP (return to provider) | In effect, specific bill types | — |
| 127 | Service not allowed for Part B Inpatient claim | LIR (line item rejection) | In effect, specific bill types | — |
111 edits in effect. Edit names are reproduced from the I/OCE edit table; the specification's full reason text, code lists and revenue-code descriptions are not reproduced. Status is read from the specification's version column and its bill type 013x edit list.
Working I/OCE edits in a denial queue
Sort the work by disposition first. Returned claims are the fastest to clear and the easiest to prevent, because almost every return-to-provider edit is a validity check that a claim scrubber can run before submission: code valid on the date of service, revenue code valid, modifier valid, dates inside the claim span. Line rejections from edits 20 and 40 point at coding and documentation; review them with the coder before resubmitting, since adding a modifier without support turns a rejection into an audit finding. Line denials such as edits 18, 49 and 106 to 108 need an appeal or a write-off decision, and the remark code on the 835 is the fastest way to tell them apart. Suspended claims need no action until the contractor asks for records. Each quarter, compare the new release against the edits your claims hit most, because a quarterly I/OCE update can add edits, change dispositions and retire edits.
The denial code reference explains each CARC and RARC with appeal steps, and the NCCI reference hub connects the edit tables behind edits 20, 40 and 106 to 108.
Where QuickIntell fits for outpatient claim edits
QuickRCM covers claim readiness, denials, posting and A/R with configurable automation and human review, which is where returned claims, rejected lines and denied lines from the outpatient code editor are corrected, resubmitted or appealed.
Frequently asked questions
What is the I/OCE?
The Integrated Outpatient Code Editor is the CMS software that Medicare Administrative Contractors run on institutional outpatient claims. It checks the codes on each line, applies the hospital NCCI code-pair and add-on code edits, assigns APCs and status indicators under the Outpatient Prospective Payment System, and returns edit numbers that tell the contractor what to do with the claim or line.
What does a return to provider (RTP) from the I/OCE mean?
The claim comes back to the hospital before it is adjudicated, so there is no remittance advice and nothing to appeal. Correct the item the edit names, such as an invalid code, revenue code, modifier or date, and resubmit the claim through the contractor's direct data entry or your clearinghouse.
Can a line item rejection be appealed?
No. A rejected line can be corrected and resubmitted but not appealed. A line item denial is the opposite: the line cannot simply be resubmitted, but the denial can be appealed. The I/OCE specification defines both dispositions this way.
What are I/OCE edits 20 and 40?
They are the hospital outpatient form of the NCCI procedure-to-procedure edits. Edit 20 marks the column-two code of a pair whose modifier indicator is 0, which no modifier can bypass; edit 40 marks the column-two code of a pair whose indicator is 1 when the line has no qualifying modifier. Both reject the line.
How often is the I/OCE updated?
Quarterly, effective January 1, April 1, July 1 and October 1, alongside the OPPS quarterly update. Each release keeps 28 prior quarters of logic so older claims are edited by the rules of their own dates.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Integrated Outpatient Code Editor (I/OCE) v27.3 quarterly data files: edit and edit disposition tablesVersion v27.3 (27.3.0) · effective 2026-10-01 · file DSC_Edit.txtSHA-256 fdfc1c896301437b…
- Integrated Outpatient Code Editor (I/OCE) CMS specifications v27.3Version v27.3 specifications · effective 2026-10-01 · file Final IntegOCEspecs_V27.3_Oct26.pdfSHA-256 df26312463bfa067…
- NCCI PTP edits, hospital outpatient, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccioph-v323r0-f1.txtSHA-256 063f41b91ef9faa2…
- NCCI Add-On Code edits, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file AOC_V2026Q4-F-MCR.xlsxSHA-256 eabb519623134549…
Disclaimer
Operational reference compiled from the CMS I/OCE quarterly release. The CARC and RARC matches are by definition; your contractor's remittance codes take precedence. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.