Glossary

An Article is a companion document to an LCD or NCD that lists the specific CPT/HCPCS codes, modifiers, and ICD-10 codes used to bill within the policy's scope. The LCD/NCD answers 'is this service covered?' — the Article answers 'which codes do I use to claim it?' Codelle surfaces articles on every CPT code-detail page and AI Coder procedure card under 'Coverage Rules Apply' alongside the parent LCD/NCD.

Example:On AI Coder's procedure card for 11302, you'll see LCD A57482 and ARTICLE A54602 — same coverage scope, different document types.

See also: LCD, NCD

Used in: AI Coder, LCD Coverage Search

Confidence scores appear on AI Coder per-criterion modifier evaluations and on Modifier Advisor results. The score reflects the AI's calibrated probability that the chart documents the criterion. High (≥80%) means the documentation clearly supports the criterion; Moderate (50–79%) means partial support — review the chart; Low (<50%) means the criterion is not yet documented and you should add the missing detail before billing. Confidence scores are calibrated against historical CMS audit outcomes; they are not a guarantee of payment.

Example:Modifier 25 evaluation on a 99213 + 11302 encounter: distinct-cc 95% · separate-exam 90% · independent-mdm 90% · site-specificity 68% (the last criterion is borderline — review the chart to confirm site documentation).

See also: Modifier rubric, Trace ID

Used in: AI Coder, Modifier Advisor

Office/outpatient E/M codes (99202–99205, 99212–99215) under the 2021+ AMA guidelines are coded by either Medical Decision Making (MDM) or total time. MDM is determined by the 2-of-3 rule across three elements: Problems Addressed, Data Reviewed & Analyzed, and Risk of Complications. Each element is scored Straightforward / Low / Moderate / High. The level you bill is the level reached by at least 2 of the 3 elements. Codelle's E/M Calculator walks you through each element with the official AMA criteria; AI Coder applies the same logic automatically and surfaces the per-element scoring on every E/M line.

Example:An established-patient visit with 2 chronic stable conditions (Problems = Low), prior records reviewed (Data = Low), and OTC-only medication management (Risk = Low) bills as 99212 (low MDM, established patient).

See also: Confidence score

Used in: AI Coder, E/M Level Calculator

ICD-10-CM uses two exclusion conventions: Excludes1 (do not code together — the conditions are mutually exclusive) and Excludes2 (not included here, but may be coded together if both are present). Excludes1 violations are hard claim errors. Codelle's Claim Scrub checks every diagnosis pair against the Excludes1 table and flags violations as FAIL. AI Coder cross-checks Excludes1 during draft and removes conflicting candidates before presenting the claim.

Example:Claim Scrub on J45.40 (asthma) + J45.50 (severe persistent asthma) returns FAIL — Excludes1 says one supersedes the other.

See also: FAIL

Used in: Claim Scrub, Official Coding Guidelines

Facility allowable applies when the service is performed in a hospital outpatient department or ambulatory surgery center. The facility bills its own facility fee for overhead; the physician's payment uses the facility-PE RVU, which is lower. The differential between non-facility and facility rates is the practice expense (PE) component. Codelle surfaces both rates on every CPT/HCPCS code-detail page.

Example:CPT 99213 in Northern NJ: $60.19 facility — $42.40 less than non-facility because the facility fee reimburses overhead separately.

See also: Non-facility allowable, RVU, Locality

FAIL appears on NCCI PTP edits with modifier indicator 0 (mutually exclusive procedures, lab-panel components, gender-specific procedure mismatches, or misuse of column-2 codes), on Claim Scrub findings that violate Excludes1 ICD-10 conventions, age/sex restrictions, MUE limits exceeded with MAI 2 or 3, or coverage criteria gaps that no modifier can override. FAIL means the claim line will be denied if submitted as-is.

Example:NCCI Validator on 43239, 43235 (UGI endoscopy with biopsy + diagnostic UGI endoscopy) returns FAIL: 'Cannot be bypassed with a modifier. These codes should never be billed together.'

See also: PASS, WEAK, NCCI PTP edit, Excludes1, MUE

Used in: AI Coder, Claim Scrub, Modifier Advisor, NCCI Edit Validator

Code sets refresh annually. ICD-10-CM changes are effective October 1 each year (FY runs October 1 through September 30); CPT and HCPCS Level II changes are effective January 1. The current fiscal year governs which descriptions, additions, deletions, and revisions apply on a date of service. Codelle indexes every revision back to FY2024 and offers a year selector on Search and code-detail pages so you can audit historical claims at the codes that were current on the original DOS. Deleted codes get an 'inactive' page with replacement-code suggestions.

Example:CPT 55700 (biopsy of prostate) was deleted FY2025→FY2026 and replaced by 55705–55714. The 55700 code-detail page renders with an 'INACTIVE' badge and the 12 closest replacement codes.

When ICD-10 went live in 2015, CMS published GEM tables to bridge legacy ICD-9 records. Each GEM mapping has a type — 'approximate' (close but not exact match), 'one-to-many' (multiple ICD-10 candidates per ICD-9), 'combination' (one ICD-9 maps to a combination of ICD-10 codes). Codelle's Crosswalks tool indexes the full GEM table; type indicators appear on every result so you understand the fidelity of the mapping. GEM is the right tool for retroactive code lookup, not for current claims (which must use ICD-10 directly).

Example:ICD-9 486 (pneumonia, organism unspecified) maps to ICD-10 J18.9 (pneumonia, unspecified organism) as an approximate one-to-one mapping.

Surgical CPT codes carry a global period that bundles pre-op, day-of, and post-op care into the procedure's fee. During the global period, related E/M visits cannot be billed separately unless modifier 24 (unrelated E/M during postop period) or 79 (unrelated procedure) applies. Codelle's Global Days Calculator computes the exact pre-op, day-of, and post-op windows from any surgery date. AI Coder surfaces the global-period badge on every procedure card; Claim Scrub flags claims that bill an E/M during another procedure's global period.

Example:CPT 27447 (total knee arthroplasty) has a 90-day global; an unrelated office visit on day 30 needs modifier 24.

Used in: Global Days Calculator

GPCI factors are published annually by CMS for each Medicare locality. For each code, the Medicare allowable is computed as: (Work RVU × Work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × Conversion Factor. Codelle surfaces the GPCI breakdown on every CPT/HCPCS code-detail page so you can see exactly how your locality adjusts each component.

Example:Northern NJ GPCI: Work 1.063 · PE 1.160 · MP 1.068 — applied to CPT 99213's RVUs to compute the $102.59 non-facility allowable.

See also: Locality, RVU

LCDs are issued by Medicare Administrative Contractors (MACs) and apply within a specific geographic jurisdiction. They define when a procedure is reasonable and necessary, which ICD-10 codes establish coverage, which diagnoses are explicitly non-covered, and the documentation requirements. Codelle indexes every active LCD nationwide and surfaces them on every CPT/HCPCS code-detail page filtered to your jurisdiction (set via your dashboard locality). Claim Scrub and AI Coder cross-check coverage at your claim's locality automatically.

Example:LCD A57482 'Billing and Coding: Removal of Benign Skin Lesions' applies to CPT 11302 in Northern NJ — Codelle surfaces it on the procedure card alongside the Coverage Rules count.

See also: NCD, Article (LCD/NCD), Locality

Used in: AI Coder, Claim Scrub, LCD Coverage Search

Medicare divides the country into ~100 localities for purposes of payment adjustment via the Geographic Practice Cost Index (GPCI). Your locality determines the work, practice expense, and malpractice multipliers applied to each RVU when computing your non-facility and facility allowables. Locality also governs which LCDs apply for coverage. Codelle's locality picker on the dashboard sets your default; AI Coder, Claim Scrub, and Fee Schedule lookups all use it unless you override per-claim.

Example:CPT 99213 in Northern NJ: $102.59 non-facility allowable, vs. $92.19 national. The $10.40 difference is the locality adjustment.

See also: GPCI, RVU, Non-facility allowable, Facility allowable, LCD

Used in: AI Coder, Claim Scrub, LCD Coverage Search

MAI 1 means the MUE applies per claim line; the same code on a separate line on the same DOS can pay separately if a modifier justifies it. MAI 2 is a date-of-service edit grounded in policy (e.g., bilateral procedures, anatomical impossibility); these are not generally bypassable. MAI 3 is a date-of-service edit grounded in clinical likelihood; you can sometimes appeal with documentation. Codelle surfaces MAI alongside the MUE limit on every code-detail page and on the NCCI Validator MUE table.

Example:CPT 99213 MAI = 3: clinical edit, generally bypassable only with strong documentation that more than 2 visits in one day were medically necessary.

See also: MUE, NCCI PTP edit

Used in: NCCI Edit Validator

Each NCCI PTP edit has a modifier indicator that determines whether a modifier can override the edit. Indicator 0 means the codes are mutually exclusive and no modifier overrides the bundling — billing both is incorrect. Indicator 1 means a modifier (e.g., 25, 59, XE, XS, XP, XU) can override the edit when documentation supports a distinct service. Indicator 9 means the indicator does not apply (rare, mostly for retired edits).

Example:On the NCCI Validator, a WEAK card carries modifier indicator 1; a FAIL card carries 0.

See also: NCCI PTP edit, WEAK, FAIL, Modifier rubric

Used in: Modifier Advisor, NCCI Edit Validator

A modifier rubric is the structured criterion set CMS expects in the chart before a modifier overrides an NCCI edit or unlocks a payment adjustment. Modifier 25 (E/M significant + separately identifiable) requires distinct chief complaint, separate exam, independent MDM, and site specificity. Modifier 59 (distinct procedural service) requires distinct anatomic site, distinct procedural session, no more specific X-modifier, and operative documentation. AI Coder evaluates every documented criterion against the note and returns a per-criterion verdict. Codelle ships 15 rubrics covering 22, 25, 50, 51, 53, 57, 58, 59, 76, 78, 79, 80, 81, 82, 95.

Example:On /codes/MODIFIER/25, you'll see all 4 Modifier 25 criteria with definitions and CMS citations. On the NCCI Validator's WEAK conflict card, the same rubric renders inline so you can check it without leaving the page.

See also: WEAK, NCCI PTP edit, Modifier indicator, Confidence score

Used in: AI Coder, Modifier Advisor, NCCI Edit Validator

MUE limits are published by CMS in three tables: Practitioner (office/clinic), Outpatient Hospital, and DME. Each row caps the units billable per beneficiary per date of service for a single code. Exceeding the limit triggers a denial unless the line splits across appropriate modifiers (76, 77, 91) or the units genuinely required exceed the cap and you can document why. The MUE Adjudication Indicator (MAI) tells you how strict the cap is.

Example:CPT 99213 has Practitioner MUE = 2 (you cannot bill more than 2 office visits, level 3 established, per patient per day).

See also: MAI, NCCI PTP edit, FAIL

Used in: Claim Scrub, NCCI Edit Validator

The National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit table is published quarterly by CMS. Each edit pair lists a Column 1 code, a Column 2 code, an effective date, a rationale category, and a modifier indicator (0, 1, or 9). Codelle indexes 3.1M+ NCCI edits and checks every pair on Claim Scrub, NCCI Validator, and AI Coder runs. PTP edits exist for both Practitioner and Hospital Outpatient settings; check the appropriate setting for your billing scenario.

Example:Pairing 99213 (E/M) with 11302 (shave excision) on the same DOS triggers PTP edit with modifier indicator 1 — billable with modifier 25 if the E/M is significant and separately identifiable.

See also: Modifier indicator, MUE, WEAK, FAIL, Modifier rubric

Used in: AI Coder, Claim Scrub, Modifier Advisor, NCCI Edit Validator

NCDs are coverage policies issued by CMS that apply nationally; they take precedence over LCDs. NCDs typically cover high-cost or high-risk procedures (cardiac devices, certain imaging, organ transplantation) and define the coverage criteria, frequency limits, and required diagnoses uniformly across all MAC jurisdictions. When both an LCD and NCD apply, the NCD governs. Codelle's LCD Search returns NCDs in the same result set; the type column distinguishes them.

Example:NCD 220.6 'PET Scans for Oncologic Conditions' applies nationally and supersedes any local PET-imaging LCD.

See also: LCD, Article (LCD/NCD), Locality

Used in: Claim Scrub, LCD Coverage Search

The Medicare physician fee schedule pays two different rates per code depending on the place of service. Non-facility (office, clinic) pays a higher rate because the practice incurs the practice expense overhead. Facility (hospital outpatient, ASC) pays a lower rate because the facility bills for that overhead separately. Codelle defaults to non-facility on the Fee Schedule lookup; AI Coder and Claim Scrub apply the appropriate rate based on the encounter context.

Example:CPT 99213 in Northern NJ: $102.59 non-facility (office) vs. $60.19 facility (hospital outpatient).

See also: Facility allowable, RVU, Locality

PASS appears on NCCI procedure-to-procedure (PTP) edits with no conflict, on Claim Scrub findings where every check (Excludes1, age/sex, modifier validity, MUE, NCCI PTP, LCD/NCD coverage) succeeded, and on AI Coder per-criterion modifier evaluations where the chart documents every rubric requirement. PASS does not guarantee payment; it means Codelle's compliance checks did not flag a problem.

Example:Claim Scrub on 99214-25, 93000 returns PASS for both procedure lines and both diagnoses.

See also: WEAK, FAIL, NCCI PTP edit, Modifier rubric

Used in: AI Coder, Claim Scrub, Modifier Advisor, NCCI Edit Validator

Medicare pays based on Relative Value Units (RVUs) multiplied by GPCI multipliers for your locality and the annual Conversion Factor. There are three RVU components: Work RVU (clinician effort), Practice Expense RVU (overhead — split into facility and non-facility), and Malpractice RVU (liability cost). The total RVU, when multiplied by the Conversion Factor and adjusted by GPCI, yields the allowable. Codelle indexes Medicare's MPFS quarterly RVU files and surfaces every component on the Fee Schedule lookup and code-detail page.

Example:CPT 99213 Northern NJ: Work 1.30 RVU + PE 1.46 RVU + MP 0.10 RVU = 2.86 total RVU. Multiplied by Conversion Factor and locality-adjusted, yields $102.59 non-facility.

See also: GPCI, Locality, Non-facility allowable, Facility allowable

Every AI request — AI Coder draft, Claim Scrub run, Modifier Advisor recommendation, AI Search query, AI Chat message — emits a unique Trace ID. The Trace ID is visible on the result and is logged server-side with the model inputs, outputs, evidence, and reasoning. If you see a wrong answer, copy the Trace ID into a support email and we can reconstruct the request. Trace IDs are retained for 30 days.

Example:On AI Coder, the Trace ID lf_t_dev_a3f82b42 appears below the drafted-claim header — click to copy.

See also: Confidence score

Used in: AI Coder, Claim Scrub

WEAK appears on NCCI PTP edits with modifier indicator 1, on AI Coder per-criterion modifier evaluations where one or more criteria are not yet documented, and on Claim Scrub findings where the line is billable but the chart needs more detail. The line is billable, but the documentation must defend the override before submission. Codelle surfaces the matching modifier rubric inline so you can see exactly which criteria need to land in the chart.

Example:NCCI Validator on 0001U, 0029U returns WEAK with the Modifier 59 rubric (Distinct anatomic site, Distinct procedural session, No more specific X-modifier applies, Operative documentation justifies separation).

See also: PASS, FAIL, Modifier rubric, NCCI PTP edit, Modifier indicator

Used in: AI Coder, Claim Scrub, Modifier Advisor, NCCI Edit Validator