This information is for the sole use of our contracted providers and contains confidential and proprietary information. Any unauthorized review, use, disclosure or distribution is prohibited by the terms of your provider agreement with HealthLink.
Inclusion of a procedure code or edit in the list below does not imply or guarantee coverage. Furthermore, Reimbursement Policies/Edits evolve over time, and we reserve the right to review and update these Reimbursement Policies/Edits periodically.
The Significant Edit listing is based on a review of historical claims data for claims processed in the prior year and is based on CPT/HCPCS codes in effect during that time. The data reflects the edit logic in place at the time the claims were processed.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from HealthLink.
Significant Edit Definition
An edit that, 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.
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. 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.
Incidental: 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.
Modifier use: Certain modifiers are only valid for specific codes (i.e., modifiers -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).
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
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.
The following is a link to all Significant Edits for HealthLink
Significant Edits Table
