Help
Verdicts: PASS, WEAK, FAIL
Every Codelle compliance check returns one of three verdicts. Here's what each one means and where you'll see them.
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.
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).
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.'
Where you'll see verdicts
- NCCI Validator — every conflict card carries a verdict pill. Learn more →
- Claim Scrub — per procedure line and per diagnosis. Learn more →
- AI Coder — per-criterion modifier evaluation, NCCI verdicts on every procedure card. Learn more →
- Modifier Advisor — per-criterion verdict on every modifier rubric. Learn more →
- Code-detail pages — NCCI Editing Policy section + Common NCCI Override Modifiers.
Need a human?
Email hello@codelle.com. Response within 1 business day.