Q&A: Creating an effective claims edit team

Q: How can coding and patient financial services staff work together to create an effective claims edit team?

A: The HIM department or coding unit may be responsible for directly overseeing a claim edits team or the HIM and coding edit work queues managed by the patient financial services team. Edits typically occur at four main points in the claims cycle:

• Healthcare billing edits. Billing edits are maintained within the organization’s billing system and are applied prior to the claim being staged to the bill scrubber.
• Bill scrubber edits. A bill scrubber is an application that performs automated claims editing to ensure the claim is appropriate and accurate for submission. Manual review for resolution of that edit may be required.
• Clearinghouse edits. Similar to a bill scrubber, a clearinghouse scrubs the claim according to specific payer/carrier requirements to ensure the claim is appropriate and accurate for submission. Manual review for resolution of that edit may be required.
• Payer rejection. Claim is now in a denied or partially denied status.

Several common sets of edits that usually fall to HIM to resolve are included in the Medicare Integrated Outpatient Code editor (I/OCE). The I/OCE is the process by which outpatient institutional claims (UB-04/837I) are reviewed to determine the correct reimbursement for services—both Outpatient Prospective Payment System (OPPS) and non-OPPS services. The I/OCE contains all edits that are applied to claims, including National Correct Coding Initiative (NCCI) edits, modifier edits, device-to-procedure edits, and nuclear medicine-to-radiopharmaceutical edits. The I/OCE applies the edits based on the dates of service on the claim and determines what services should be considered for reimbursement based on the Medicare billing rules. The I/OCE then applies the programmed reimbursement methodology to reimburse the institutional provider for the services reported (CMS, Outpatient Code Editor, 2018).

Reference

Centers for Medicare and Medicaid Services. (CMS). (2018). Outpatient code editor. Retrieved from www.cms.gov/ Medicare/Coding/OutpatientCodeEdit/.

Note: For more information on managing claims edits, see The Contemporary Guide to Health Information Management.