Age edits: Age edits occur when the provider assigns an age-specific procedure of diagnosis code to a patient whose age is outside the designated age range.

Assistant Surgeon: Allowance for an assistant surgeon is based on CMS guidelines. Codes where an assistant surgeon is allowed are priced at 20% of the allowable. HealthLink recognizes modifiers 80, 81, 82, and AS for assistant surgeons. The assistant surgeon must bill their own services; they cannot be billed by the primary surgeon.

Custom Edit: Edits that differ from the standard claims editing software utilized.

Edit: Means a practice or procedure pursuant to which one or more adjustments are made to CPT®Codes or HCPCS Level II Codes included in a claim that result in (a) payment being made based on some, but not all, of the CPT®Codes or HCPCS Level II Codes included in the claim; (b) payment being made based upon different CPT®Codes or HCPCS Level II Codes than those included in the claim; (c) payment for one or more of the CPT®Codes or HCPCS Level II Codes included in the claim being reduced by application of Multiple Procedure Logic; (d) payment for one or more of the CPT®Codes or HCPCS Level II Codes being denied; or (e) any combination of the above.

Gender Specific Edits: Sex or gender specific edits occur when the provider assigns a gender-specific procedure or diagnosis code to a patient of the opposite sex.

Global Surgery: The global surgery package concept for the reimbursement of surgical services is utilized in the processing of claims related to the surgical service. The global surgical package applies to all surgical procedures. The RBRVS fee schedule from CMS is the source used to determine the pre and postoperative periods associated with each surgical procedure. Services included in the surgical allowance include but are not limited to the pre-operative visits after the decision for surgery, intra-operative services, follow-up visits, anesthesia by the surgeon and other services during the post-operative period.

Incidental/Integral: An incidental Procedure is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure.

Multiple Surgery Rule Processing: The multiple surgery processing rule is applied when a physician performs separate procedures on the same patient during the same operative session. These separate procedures are not incidental to the primary procedure and are separately payable. The multiple surgery rule is applied as follows: 100% of the fee schedule amount is allowed for the procedure with the highest unit value and 50% of the fee schedule amount is allowed for the second and all subsequent procedures. Add-on Codes listed in Appendix D and Modifier 51 exempt codes listed in Appendix E of the American Medical Association’s Current Procedural Terminology (CPT)® book, are exempt from the Multiple Surgery Processing Rule and are allowed at 100% of the fee schedule allowance.

Mutually Exclusive: Mutually exclusive procedures are two or more procedures usually not performed during the same patient encounter on the same date of service.

Significant Edit: Means an Edit that Company reasonably believes, based on its experience with submitted claims, will cause, on the initial review of submitted claims, the denial of or reduction in payment for a particular CPT® Code or HCPCS Level II Code more than two-hundred and fifty (250) times per year in any state in which Company operates.

Unbundling: Procedure unbundling occurs when two or more procedures are used to describe a service when a single, more comprehensive procedure exists that more accurately describes the complete service performed by a provider. In this instance, the two codes may be replaced with the more appropriate code by our bundling system.