Customer detail

ISpine

25
live contracts
0
cannot fire
18
calc types
1
SQL bodies
0
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment245
PercentOfFees42
MidLevelProviderAdjustment41
MedicareMultipleProcedureAdjustment29
LesserOfAdjustment25
ChargeLevelSqlAdjustment22
MedicareMultipleRadiologyAdjustment22
MedicareBilateralSurgeryAdjustment21
MedicareMultipleTherapyAdjustment19
MedicareMultipleEndoscopyAdjustment17
FlatPercentOfCharges16
MedicareRVU13
MedicareAnesthesia13
MedicareLab10
MedicareDME6
MedicareDrug6
MedicareASC5
MedicareMultipleSurgeryAdjustment2

Contracts

Each is one fee logic. Base terms are first-match-wins; adjustments all apply, in order. Expand to see the terms.

BCBS Commercial-Facility2 base · 7 adj
BCBS Commercial
Facility · all facilities · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 101.8% of the BCBS Commercial-Facility-Fees fee schedule
  2. 25% of billed charges
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment — when Modifier 50 is present
  2. Medicare multiple-procedure reduction — base codes 1, 2, 3; pays 100/50/50/50/50/50% — when Modifier 55 is absent
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 52 present → 50% of the running amount
  5. modifier 53 present → 50% of the running amount
  6. modifier 73 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
BCBS-Commercial-PhysicalOccupationalMedicine-Profee6 base · 22 adj
BCBS-Commercial-PhysicalOccupationalMedicine
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 101.8% of the BCBS-Comm-PO-NonFacility-Profee fee schedule — when FacilityType in Clinic
  2. 101.8% of the BCBS-Comm-PO-Facility-Profee fee schedule
  3. 101.8% of the BCBS-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic
  4. 101.8% of the BCBS-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC
  5. 101.8% of the BCBS-NonRVU-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC
  6. 101.8% of the BCBS-NonRVU-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  2. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  3. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  5. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode G0444 is present
  6. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  7. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  8. Medicare multiple-endoscopy reduction
  9. Medicare multiple-radiology reduction — base codes 4
  10. Medicare bilateral-surgery adjustment
  11. modifier 22 present → 135% of the running amount
  12. modifier 54 present → 80% of the running amount
  13. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. modifier 81 present → 16% of the running amount
  18. modifier 82 present → 16% of the running amount
  19. modifier AS present → 14% of the running amount
  20. modifier CO present → 85% of the running amount
  21. modifier CQ present → 85% of the running amount
  22. cap each charge and the account total at 90% of billed charges
BCBS-Commercial-Profee8 base · 22 adj
BCBS Commercial
Profee · all facilities · 2024-07-01 → 2025-12-31
Base terms — first match wins
  1. 101.8% of the BCBS-Comm-AA-Facility-Profee fee schedule — when Facility in ANESTHESIA ASSOCIATES PLLC; FacilityType in ASC, Home, Hospital, Hospital/ASC
  2. 101.8% of the BCBS-Comm-AA-NonFacility-Profee fee schedule — when Facility in ANESTHESIA ASSOCIATES PLLC; FacilityType in Clinic
  3. 101.8% of the BCBS-Therapy-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC; ProviderType in Physical Therapist
  4. 101.8% of the BCBS-Therapy-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic; ProviderType in Physical Therapist
  5. 101.8% of the BCBS-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic
  6. 101.8% of the BCBS-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC
  7. 101.8% of the BCBS-NonRVU-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC
  8. 101.8% of the BCBS-NonRVU-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  2. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  3. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  5. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode G0444 is present
  6. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  7. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  8. Medicare multiple-endoscopy reduction
  9. Medicare multiple-radiology reduction — base codes 4
  10. Medicare bilateral-surgery adjustment
  11. modifier 22 present → 135% of the running amount
  12. modifier 54 present → 80% of the running amount
  13. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. modifier 81 present → 16% of the running amount
  18. modifier 82 present → 16% of the running amount
  19. modifier AS present → 14% of the running amount
  20. modifier CO present → 85% of the running amount
  21. modifier CQ present → 85% of the running amount
  22. cap each charge and the account total at 90% of billed charges
BCBS-Commercial-Profee8 base · 22 adj
BCBS Commercial
Profee · all facilities · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 101.8% of the BCBS-Comm-AA-Facility-Profee fee schedule — when Facility in ANESTHESIA ASSOCIATES PLLC; FacilityType in ASC, Home, Hospital, Hospital/ASC
  2. 101.8% of the BCBS-Comm-AA-NonFacility-Profee fee schedule — when Facility in ANESTHESIA ASSOCIATES PLLC; FacilityType in Clinic
  3. 101.8% of the BCBS-Therapy-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC; ProviderType in Physical Therapist
  4. 101.8% of the BCBS-Therapy-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic; ProviderType in Physical Therapist
  5. 101.8% of the BCBS-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic
  6. 101.8% of the BCBS-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC
  7. 101.8% of the BCBS-NonRVU-Comm-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital, Hospital/ASC
  8. 101.8% of the BCBS-NonRVU-Comm-NonFacility-Profee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  2. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  3. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  5. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode G0444 is present
  6. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  7. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  8. Medicare multiple-endoscopy reduction
  9. Medicare multiple-radiology reduction — base codes 4
  10. Medicare bilateral-surgery adjustment
  11. modifier 22 present → 135% of the running amount
  12. modifier 54 present → 80% of the running amount
  13. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. modifier 81 present → 16% of the running amount
  18. modifier 82 present → 16% of the running amount
  19. modifier AS present → 14% of the running amount
  20. modifier CO present → 85% of the running amount
  21. modifier CQ present → 85% of the running amount
  22. cap each charge and the account total at 90% of billed charges
BCBS-Medicare-Facility1 base · 19 adj
BCBS Med Adv
Facility · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 0, 2; pays 100/50% — when ProcedureCode 63650 is absent; ProcedureCode 63685 is absent; ProcedureCode 64636 is absent; ProcedureCode 64484 is absent; ProcedureCode 64494 is absent; ProcedureCode 64491 is absent; ProcedureCode 63661 is absent; ProcedureCode 64634 is absent; ProcedureCode 64488 is absent; ProcedureCode 63663 is absent; ProcedureCode 22515 is absent; ProcedureCode 64486 is absent; ProcedureCode 64555 is absent
  2. Medicare multiple-procedure reduction — base codes 9; pays 100/50/50/50/50% — when ProcedureCode G0260 is present
  3. mid-level provider reduction (by NUCC taxonomy)
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Health Partners Commercial-Profee5 base · 25 adj
Health Partners Commercial
Profee · all facilities · 2025-01-01 → 2025-12-31
Base terms — first match wins
  1. 101.8% of Medicare anesthesia
  2. 101.8% of the Health Partners Commercial Profee 2025 fee schedule — when FacilityType in Clinic
  3. 101.8% of the Health Partners Commercial Facility Profee 2025 fee schedule — when FacilityType in ASC, Home, Hospital
  4. 100% of Medicare RVU (rates as of 2024-01-01)
  5. 70% of billed charges
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  2. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  3. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  5. Medicare bilateral-surgery adjustment
  6. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  7. Medicare multiple-procedure reduction — base codes 5; pays 100/75/75/75/75/75%
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  9. Medicare multiple-endoscopy reduction
  10. Medicare multiple-radiology reduction — base codes 4
  11. modifier 22 present → 135% of the running amount
  12. modifier 54 present → 80% of the running amount
  13. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. modifier 81 present → 16% of the running amount
  18. modifier 82 present → 16% of the running amount
  19. modifier AS present → 14% of the running amount
  20. modifier QY present → 70% of the running amount
  21. modifier QK present → 70% of the running amount
  22. modifier QX present → 70% of the running amount
  23. modifier CQ present → 85% of the running amount
  24. modifier CO present → 85% of the running amount
  25. cap each charge and the account total at 100% of billed charges
Health Partners Commercial-Profee5 base · 25 adj
Health Partners Commercial
Profee · all facilities · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 101.8% of Medicare anesthesia
  2. 101.8% of the Health Partners Commercial Profee 2025 fee schedule — when FacilityType in Clinic
  3. 101.8% of the Health Partners Commercial Facility Profee 2025 fee schedule — when FacilityType in ASC, Home, Hospital
  4. 100% of Medicare RVU (rates as of 2024-01-01)
  5. 70% of billed charges
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  2. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  3. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  5. Medicare bilateral-surgery adjustment
  6. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  7. Medicare multiple-procedure reduction — base codes 5; pays 100/75/75/75/75/75%
  8. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  9. Medicare multiple-endoscopy reduction
  10. Medicare multiple-radiology reduction — base codes 4
  11. modifier 22 present → 135% of the running amount
  12. modifier 54 present → 80% of the running amount
  13. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. modifier 81 present → 16% of the running amount
  18. modifier 82 present → 16% of the running amount
  19. modifier AS present → 14% of the running amount
  20. modifier QY present → 70% of the running amount
  21. modifier QK present → 70% of the running amount
  22. modifier QX present → 70% of the running amount
  23. modifier CQ present → 85% of the running amount
  24. modifier CO present → 85% of the running amount
  25. cap each charge and the account total at 100% of billed charges
Health Partners Medicare - Profee4 base · 22 adj
Health Partners Med Adv
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 100% of Medicare RVU
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  2. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  3. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  5. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  6. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  7. Medicare multiple-endoscopy reduction
  8. Medicare multiple-radiology reduction — base codes 4
  9. Medicare bilateral-surgery adjustment
  10. modifier 22 present → 135% of the running amount
  11. modifier 54 present → 80% of the running amount
  12. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  13. modifier 62 present → 62.5% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Health Partners Network Access Profee5 base · 25 adj
Health Partners Network Access
Profee · 1 named facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 126.8% of the Health Partners Network Access Profee 2025 fee schedule — when FacilityType in Clinic ⚠︎ named “125% Health Partners Network Access Profee with MNcare Tax” but configured at 126.8%
  2. 126.8% of the Health Partners Network Access Facility Profee 2025 fee schedule — when FacilityType in ASC, Home, Hospital ⚠︎ named “125% Health Partners Network Access Facility Profee MNcare Tax” but configured at 126.8%
  3. 101.8% of Medicare anesthesia
  4. 100% of Medicare RVU (rates as of 2024-01-01)
  5. 70% of billed charges
Adjustments — all apply, in order
  1. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  2. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  3. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  4. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  5. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  6. Medicare multiple-procedure reduction — base codes 5; pays 100/75/75/75/75/75%
  7. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  8. Medicare multiple-endoscopy reduction
  9. Medicare multiple-radiology reduction — base codes 4
  10. Medicare bilateral-surgery adjustment
  11. modifier 22 present → 120% of the running amount
  12. modifier 54 present → 75% of the running amount
  13. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  14. modifier 62 present → 62.5% of the running amount
  15. modifier 78 present → 70% of the running amount
  16. modifier 80 present → 16% of the running amount
  17. modifier 81 present → 16% of the running amount
  18. modifier 82 present → 16% of the running amount
  19. modifier AS present → 14% of the running amount
  20. modifier QY present → 50% of the running amount
  21. modifier QK present → 50% of the running amount
  22. modifier QX present → 50% of the running amount
  23. cap each charge and the account total at 100% of billed charges
  24. modifier CO present → 85% of the running amount
  25. modifier CQ present → 85% of the running amount
HealthPartners-ASC-Facility3 base · 14 adj
Health Partners Commercial
Facility · 2 named facilities · 2025-06-01 → 2999-12-31
Base terms — first match wins
  1. 101.8% of the HealthPartners-Commercial-Facility-APC-Fees fee schedule ⚠︎ named “100% Health Partners APC with CF 2025 with MNCare Tax” but configured at 101.8%
  2. 101.8% of the HealthPartners-Commercial-Facility-Fees fee schedule
  3. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment — when Modifier 50 is present
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-procedure reduction — base codes 1, 2, 3, 9; pays 100/50/50/50/50/50% — when ProcedureCode A4550 is absent
  4. Medicare multiple-radiology reduction — base codes 4
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Medica-MSC-ASC3 base · 14 adj
Medica Commercial
Facility · 1 named facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of billed charges — when RevCode 0278 is present
  2. 100% of the Medica-Commercial-MSC-Facility-Fees fee schedule
  3. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment — when Modifier 50 is present
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-procedure reduction — base codes 0, 1, 2, 3, 4, 5, 6, 7, 8, 9; pays 100/50/50/50/50/50%
  4. Medicare multiple-radiology reduction — base codes 4
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. cap each charge and the account total at 100% of billed charges
Medica-Medicare-MSC-ASC1 base · 13 adj
Medica Medicare
Facility · 1 named facilities · 2023-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2, 3, 9; pays 100/50% — when Modifier 55 is absent; ProcedureCode 63650 is absent; ProcedureCode 64555 is absent; ProcedureCode 63651 is absent
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 78 present → 70% of the running amount
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 14% of the running amount
  13. cap each charge and the account total at 100% of billed charges
Medica-Medicare-PCOM-ASC1 base · 13 adj
Medica Medicare
Facility · 1 named facilities · 2023-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2, 3, 9; pays 100/50% — when Modifier 55 is absent; ProcedureCode 63650 is absent; ProcedureCode 64555 is absent; ProcedureCode 63651 is absent
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 78 present → 70% of the running amount
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 14% of the running amount
  13. cap each charge and the account total at 100% of billed charges
Medica-PCOM-ASC1 base · 12 adj
Medica Commercial
Facility · 1 named facilities · 2023-04-01 → 2999-12-31
Base terms — first match wins
  1. 80.9% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 4
  3. modifier 22 present → 135% of the running amount
  4. modifier 54 present → 80% of the running amount
  5. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  6. modifier 62 present → 62.5% of the running amount
  7. modifier 78 present → 70% of the running amount
  8. modifier 80 present → 16% of the running amount
  9. modifier 81 present → 16% of the running amount
  10. modifier 82 present → 16% of the running amount
  11. modifier AS present → 14% of the running amount
  12. cap each charge and the account total at 100% of billed charges
Medica-Profee6 base · 19 adj
Medica Commercial
Profee · all facilities · 2021-04-01 → 2999-12-01
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Medica-MidLevel-Profee-Clinic fee schedule — when FacilityType in Clinic; ProviderType in Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physician Assistant
  3. 100% of the Medica-MidLevel-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital; ProviderType in Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physician Assistant
  4. 100% of the Medica-MD-Profee-Clinic fee schedule — when FacilityType in Clinic
  5. 100% of the Medica-MD-Profee-Hospital fee schedule — when FacilityType in ASC, Hospital
  6. 60% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 5; pays 100/75/75/75/75/75%
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. Medicare multiple-endoscopy reduction
  5. Medicare multiple-radiology reduction — base codes 4
  6. modifier 54 present → 80% of the running amount
  7. Medicare bilateral-surgery adjustment
  8. modifier 22 present → 135% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Medicare5 base · 22 adj
BCBS Med Adv
Profee · all facilities · 2024-01-01 → 2999-12-31
Medicare
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia — when Facility in ANESTHESIA ASSOCIATES PLLC
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 10021–69990
  7. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 70010–79999
  8. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 90281–98999
  9. mid-level provider reduction (by NUCC taxonomy) — when CodeRange in 99091–99499
  10. modifier 22 present → 135% of the running amount
  11. modifier 54 present → 80% of the running amount
  12. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  13. modifier 62 present → 62.5% of the running amount
  14. modifier 78 present → 70% of the running amount
  15. modifier 80 present → 16% of the running amount
  16. modifier 81 present → 16% of the running amount
  17. modifier 82 present → 16% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Medicare-ASC1 base · 20 adj
Medicare
Facility · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-surgery reduction — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
UHC-Commercial-Facility2 base · 7 adj
UHC Commercial
Facility · 1 named facilities · 2025-01-01 → 2026-01-31
Base terms — first match wins
  1. 100% of the United-ASC-Rates fee schedule
  2. 0% of billed charges ⚠︎ named “25% of Billed Charges” but configured at 0%
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment — when Modifier 50 is present
  2. Medicare multiple-procedure reduction — base codes 0, 1, 2, 3, 9; pays 100/50/25/0/0/0% — when Modifier 55 is absent
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 52 present → 50% of the running amount
  5. modifier 53 present → 50% of the running amount
  6. modifier 73 present → 50% of the running amount
  7. cap the account total at 100% of billed charges
UHC-Commercial-Facility2 base · 7 adj
UHC Commercial
Facility · 1 named facilities · 2026-02-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the United-ASC-Rates fee schedule
  2. 0% of billed charges ⚠︎ named “25% of Billed Charges” but configured at 0%
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment — when Modifier 50 is present
  2. Medicare multiple-procedure reduction — base codes 0, 1, 2, 3, 9; pays 100/50/25/0/0/0% — when Modifier 55 is absent
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 52 present → 50% of the running amount
  5. modifier 53 present → 50% of the running amount
  6. modifier 73 present → 50% of the running amount
  7. cap each charge and the account total at 100% of billed charges
UHC-Commercial-Profee10 base · 19 adj
UHC Commercial
Profee · all facilities · 2023-01-01 → 2025-09-30
Base terms — first match wins
  1. 80% of Medicare lab (rates as of 2017-01-01) — when CodeRange in 80047–80076; CodeRange in 82000–82999; CodeRange in 81000–81003; CodeRange in 85000–85999; CodeRange in 87000–87999; CodeRange in 80305–80307
  2. 51% of Medicare lab (rates as of 2017-01-01)
  3. 50% of Medicare DME (rates as of 2017-01-01)
  4. 100% of Medicare drug
  5. 100% of Medicare anesthesia (rates as of 2017-01-01) — when ProviderType in Clinic/Center, Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physical Therapist +2
  6. 100% of the Fixed-Fees fee schedule
  7. 100% of Medicare anesthesia (rates as of 2017-01-01)
  8. 170% of Medicare RVU (rates as of 2017-01-01) — when ProviderType in Clinic/Center, Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physical Therapist +2
    • CodeRange 99202–99499 → 170%
    • CodeRange 10021–69990 → 170%
    • CodeRange 92002–92499 → 170%
    • CodeRange 92920–93799 → 170%
    • CodeRange 97010–97799 → 85%
    • CodeRange 92002–92499 → 170%
    • CodeRange G0442–G0442 → 170%
  9. 185% of Medicare RVU (rates as of 2017-01-01)
    • CodeRange 99202–99499 → 185%
    • CodeRange 10021–69990 → 185%
    • CodeRange 92002–92499 → 185%
    • CodeRange 92920–93799 → 185%
    • CodeRange 97010–97799 → 85%
    • CodeRange 92002–92499 → 185%
    • CodeRange G0442–G0444 → 185%
  10. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
UHC-Commercial-Profee-202510 base · 19 adj
UHC Commercial
Profee · all facilities · 2025-10-01 → 2026-09-30
Base terms — first match wins
  1. 60% of Medicare lab (rates as of 2020-01-01) — when CodeRange in 80047–80076; CodeRange in 82000–82999; CodeRange in 81000–81003; CodeRange in 85000–85999; CodeRange in 87000–87999; CodeRange in 80305–80307
  2. 42% of Medicare lab (rates as of 2020-01-01)
  3. 40% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare drug
  5. 100% of Medicare anesthesia (rates as of 2020-01-01) — when ProviderType in Clinic/Center, Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physical Therapist +2
  6. 100% of the Fixed-Fees fee schedule
  7. 100% of Medicare anesthesia (rates as of 2020-01-01)
  8. 125% of Medicare RVU (rates as of 2020-01-01) — when ProviderType in Clinic/Center, Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physical Therapist +2
    • CodeRange 99202–99499 → 125%
    • CodeRange 10021–69990 → 125%
    • CodeRange 92002–92499 → 125%
    • CodeRange 92920–93799 → 125%
    • CodeRange 97010–97799 → 85%
    • CodeRange 92002–92499 → 125%
    • CodeRange G0442–G0442 → 125%
  9. 149% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 99202–99499 → 149%
    • CodeRange 10021–69990 → 149%
    • CodeRange 92002–92499 → 149%
    • CodeRange 92920–93799 → 149%
    • CodeRange 97010–97799 → 85%
    • CodeRange 92002–92499 → 149%
    • CodeRange G0442–G0444 → 149%
  10. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
UHC-Commercial-Profee-202610 base · 19 adj
UHC Commercial
Profee · all facilities · 2026-10-01 → 2099-12-31
Base terms — first match wins
  1. 60% of Medicare lab (rates as of 2020-01-01) — when CodeRange in 80047–80076; CodeRange in 82000–82999; CodeRange in 81000–81003; CodeRange in 85000–85999; CodeRange in 87000–87999; CodeRange in 80305–80307
  2. 42% of Medicare lab (rates as of 2020-01-01)
  3. 40% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare drug
  5. 100% of Medicare anesthesia (rates as of 2020-01-01) — when ProviderType in Clinic/Center, Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physical Therapist +2
  6. 100% of the Fixed-Fees fee schedule
  7. 100% of Medicare anesthesia (rates as of 2020-01-01)
  8. 130% of Medicare RVU (rates as of 2020-01-01) — when ProviderType in Clinic/Center, Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physical Therapist +2
    • CodeRange 99202–99499 → 130%
    • CodeRange 10021–69990 → 130%
    • CodeRange 92002–92499 → 130%
    • CodeRange 92920–93799 → 130%
    • CodeRange 97010–97799 → 85%
    • CodeRange 92002–92499 → 130%
    • CodeRange G0442–G0442 → 130%
  9. 153.5% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 99202–99499 → 153.5%
    • CodeRange 10021–69990 → 153.5%
    • CodeRange 92002–92499 → 153.5%
    • CodeRange 92920–93799 → 153.5%
    • CodeRange 97010–97799 → 85%
    • CodeRange 92002–92499 → 154%
    • CodeRange G0442–G0444 → 154%
  10. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
UHC-Medicare-AA-Profee2 base · 18 adj
UHC Med Adv
Profee · 1 named facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 25% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
UHC-Medicare-Profee9 base · 18 adj
UHC Med Adv
Profee · 3 named facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 80% of Medicare lab (rates as of 2017-01-01) — when CodeRange in 80047–80076; CodeRange in 82000–82999; CodeRange in 81000–81003; CodeRange in 85000–85999; CodeRange in 87000–87999; CodeRange in 80305–80307
  3. 51% of Medicare lab
  4. 100% of Medicare drug
  5. 50% of Medicare DME
  6. 85% of Medicare RVU — when ProviderType in Clinic/Center, Nurse Anesthetist, Certified Registered, Nurse Practitioner, Physical Therapist +3
  7. 100% of Medicare RVU
  8. 100% of the Fixed-Fees fee schedule
  9. 25% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Workers Comp-ASC1 base · 20 adj
Workers Comp
Facility · 2 named facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 101.8% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-surgery reduction — pays 100/50%
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges