Medicare Fee-for-Service Editing

The Centers for Medicare and Medicaid Services (CMS) is underway with implementation activities to convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0.

As part of this implementation, Medicare Fee-for-Service (FFS) is utilizing codes sets for editing of the inbound ASC X12 version 5010 transactions.  These codes sets are listed in the ASC X12 Technical Report Type 3 (TR3), also known as an Implementation Guide.

“Not Otherwise Classified” (NOC) codes

To meet the requirements of the TR3 for proper editing of the NOC codes, Medicare created an NOC code set for editing Medicare transactions only.  This code set is generated using the following code sets:

• Annual American Medical Association(AMA) Current Procedural Terminology (CPT) Listing
• Annual CMS Healthcare Common Procedure Coding System (HCPCS) Listing
• Quarterly CMS HCPCS Listing

The NOC code set consists of CPT and HCPCS codes that meet the following criteria:

• Procedure code ends in “99” and the procedure code has one of the words or phrases in the description:
  • Not Otherwise Classified;
  • Not Otherwise;
  • Unlisted;
  • Not Listed;
  • Unspecified;
  • Unclassified;
  • Not Otherwise Specified;
  • Non-specified;
  • Not Elsewhere Specified;
  • Not Elsewhere;
  • Nos (Note: Includes “nos”, “nos;”, “nos,”);
  • Noc (Note: Includes “noc”, “noc;”, “noc,”);
• Procedure code has one of the words or phrases in the description:
  • Not Otherwise Classified;
  • Not Otherwise;
  • Unlisted;
  • Not listed;
  • Unspecified;
  • Unclassified;
  • Not otherwise specified;
  • Non-specified;
  • Not elsewhere specified;
  • Not elsewhere;
  • Nos (Note: Include "nos ", "nos;", "nos,");
  • Noc (Note: Include "noc ", "noc;", "noc,");

Updates

Medicare will be updating the code set on a quarterly basis (January, April, July, and October) as the parent code sets are updated, so be sure to check back for updates.