The logic evaluates the codes against accepted standards and Hometown Health ’ s payment policy .
There are thousands of edits in the logic of the claims review system . Below are the most common payment policy edits that are applied to evaluate claims . Providers may always request the rationale of a particular claims payment policy edit or appeal any decision related to an edit that is applied to a claim .
Age Conflicts
An age conflict occurs when the provider assigns an age-specific procedure to a patient whose age is outside of the designated age range . Age conflict edits may include the following :
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• Newborn procedure ; age should be less than 1 year
• Pediatric procedure ; age should be 1-17 years
• Maternity procedure ; age should be 12-55 years
• Adult procedure ; age should be over 14 years
The edit comment may indicate “ THE CPT CODE USED IS INAPPROPRIATE FOR THE MEMBER ’ S AGE ”
Assistant Surgeon Edit
As defined by The American College of Surgeons ( ACS ), CPT codes related to surgery procedures are designated into the following categories :
• Assistant surgeon always allowed or
• Assistant surgeon never allowed
This rationale is based on the fact that the ACS determines these designations using clinical guidelines versus statistical measures .
In contrast , CMS ’ s assistant reimbursement policy is based solely on the frequency ( via a national sample ) in which a specific procedure is reported with an assistant surgeon modifier . Consequently , clinical logic is not used for the CMS determination of designations for assistant surgeons .
As a result , Hometown Health may apply the following edits :
• Assistant surgery reduction – All lines of the assistant surgeon ’ s claim are reduced based on a percentage of the contract allowance .
• Assistant surgeon not allowed – All lines of the assistant surgeon ’ s claims are denied .