Q&A: Claim edits across departments

November 13, 2017
Medicare Web

Q. How should facilities approach claim edits that must be made across departments, such as imaging and surgery?

A. It’s possible the departments may have correctly charged their individual services and codes. However, when the codes are combined on the claim for the same date of service, the code pair may not be acceptable.

The HIM/coding department will likely be the first to identify these edits. The edit may trigger once HIM applies the CPT® procedure codes or once the ICD-10-CM diagnosis codes have been added. If HIM/coding does not code the account, it is possible that the edit could trigger in the patient financial services department during prebilling.

Root cause analysis for services across departments follows a somewhat similar process as does the analysis for services within the same department. However, the options for charge structure revisions to solve the edits may be different.

For more information, see Medicare Billing Edits: A Guide to Regulation, Research, and Resolution.

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