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Significant Edits
An edit that is based on experience with submitted claims will cause, on initial review of submitted claims, the denial or reduction in payment for a particular CPT® code or HCPCS Level II code more than two-hundred and fifty (250) times per year.
The following is a link to all Significant Edits for HealthLink: Significant Edits Table
Descriptions:
Age edit: Age edits occur when the provider assigns an age-specific procedure or diagnosis code to a patient whose age is outside the designated age range.
Anesthesia: Time must be submitted when general anesthesia codes (00100-01999) are billed. When modifiers QY, QK, QX, or AS are billed, the allowance is 50% of the fee schedule allowable.
Assistant Surgeon: Allowance for an assistant surgeon is based on CMS guidelines. HealthLink recognizes modifiers 80, 81, 82, and AS for assistant surgeons. Codes assistant surgeon bills modifiers 80, 81 and 82 are allowed at 16%; codes an assistant surgeon bills modifier AS is allowed at 14% of the allowable. The assistant surgeon must bill his or her own services; he or she cannot be billed by the primary surgeon.
Edit: Means a practice or procedure pursuant to which one or more adjustments are made in CPT® Codes or HCPCS Level II Codes included in a claim that results 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 post-operative 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.
Mutually Exclusive: Mutually exclusive procedures are two or more procedures usually not performed during the same patient counter on the same date of service.
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.
Venipuncture/Specimen Collection: Drawing blood, specimen collection or conveyance of the specimen is considered to be integral to the performance of a laboratory test, and is not allowed separately.
Modifier use
Certain modifiers are only valid for specific codes (i.e. modifier 25 and 57 are only valid with E&M services, modifier 26 is not valid for surgical procedures as they are inherently professional in nature). As of the date of publication of this manual, HealthLink includes a special coding update section in the HealthLink Provider newsletter, In Touch.
Modifier 25: HealthLink generally will recognize modifier 25 for payment purposes, when it is appropriately reported from both a clinical and a coding perspective to identify a significant, separately identifiable Evaluation and Management service by the same physician on the same day of a procedure or other service.
Modifier 59: HealthLink generally will recognize modifier 59 for payment purposes, when it is appropriately reported from both a clinical and coding perspective. However, in certain situations, described below, HealthLink will not recognize modifier 59 for payment purposes.
| 1. | "Duplicate" Procedures. HealthLink will not pay for "duplicate" procedures performed on the same patient on the same date of service, even if a provider reports modifier 59 with these procedures. "Duplicate" procedures, as used in this paragraph, fall into the following categories: |
| a. | If the description of a procedure code contains either the word "bilateral" or the phrase "unilateral/bilateral," the procedure code can be reported only once for a covered procedure performed on a single date of service (and the reporting of any additional such procedures performed on the same date will be considered non-payable "duplicates"); |
| b. | If the description of a procedure code specifies "unilateral" procedure, and there is another procedure code that specifies "bilateral" for the same procedure, the "unilateral" procedure code can be reported only once for a covered procedure performed on a single date of service (and the reporting of any additional such "unilateral" procedures performed on the same date will be considered non-payable "duplicates"); |
| c. | If the description of a procedure code specifies a "single" procedure, and there is another procedure code that specifies "multiple" procedures for the same procedure, the "single" procedure code can be reported only once for a covered procedure performed on a single date of service (and the reporting of any additional such "single" procedures performed on the same date will be considered non-payable "duplicates"); and |
| d. | If the description of a procedure code states that the procedure may be performed a specified number of times on a single date of service, a provider should not report the performance of any such procedure beyond the specified number of times (and the reporting of any additional such procedures performed on the same date will be considered non-payable "duplicates"). |
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. Internal processing guidelines also cause some codes such as spinal injections and cardiac bypass to be allowed at 100% even though they are not add-on or modifier 51 exempt codes.
Multiple Surgery Guidelines
Customized Edits
Custom claim edits differ from the standard claims editing software used by HealthLink. At this time, HealthLink does not have any customized edits.
