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Claim Editing Software

For Greater Accuracy and Enhanced Revenue

Claim editor or “claim scrubber” software is rapidly becoming an industry-standard feature of medical billing software. But only our claim editing application verifies both professional and institutional claims from the payer’s perspective using the industry’s most comprehensive medical necessity database.

We give healthcare organizations—both physician practices and hospitals — access to essentially the same technology payers use. By editing claim files prior to submission, Claim Scrubbing can improve claim validity, improve cash flow, and demonstrate clinical defensibility.

Taken together, LCD/NCD data provides coverage rules for a small fraction of all possible CPT® codes. Our Claim Scrubbing software adds an additional proprietary clinical medical necessity database, more than doubling the number of CPT codes to cover virtually all possible ICD-9/CPT code combinations. Our medical content database, constantly updated and improved over the course of more than 30 years, yields a depth of edits no other coding software provider can match.

What It Does

From front-end format requirements to our proprietary medical necessity checks, ClaimStaker analyzes claim files for more standard, built-in edits than any similar product. The following list is just part of what Claim Scrubbing can do:

Diagnosis Code Edits

  • ICD-9 validity
    • Ultimate specificity
    • Secondary code suitability
    • Patient gender
  • E-codes
  • V-codes

Medical Necessity Edits

  • Part A and Part B LCD/NCD
  • Proprietary (Clinically Defensible)
  • E&M level of service
  • Links to LCD/NCD policies

Procedure Code Edits

  • CPT validity, including patient gender and age
  • Correct Coding Initiative (CCI) bundling
  • HCPCS validity
  • RVU sequencing
  • Modifier usage
  • Global fee periods
  • PQRI / PQRS*
  • ePrescribe incentives

Claim-Level Technical Edits

  • NPI (provider number) validity
  • Accident indicators/date accuracy
  • Place of service appropriateness
  • Charge versus allowance analysis
  • Overall proper claim completion

Outpatient Prospective Payment System (OPPS) Edits

  • Outpatient Code Editor (OCE) validation
  • Revenue/HCPCS code combinations
  • Condition Code, Occurrence Code, and
  • Value Code checks

File Format Edits

  • ANSI 837 EDI claim file format verification
  • Situational segment and data element evaluation
  • Maximum/minimum held lengths
  • Proper qualifier usage
  • Data content accuracy

Special Features

Claim Scrubbing accepts claim files created by most hospital billing and practice management programs on the market today. And it requires no change to existing programming. Even though end users maintain their existing billing software, no duplicate data entry is necessary.

Optimize Revenue with E&M Edits

A unique feature, we can apply an acuity level to each ICD-9 code in a claim—a more reliable way to avoid the risk of over-coding and prevent the revenue loss of under-coding for evaluation and management services.

Do-it-yourself Customizable Edits

The ease of customization truly sets this solution apart. In addition to accommodating unusual insurance or managed care rules, each standard edit can be enabled or disabled for specific claim types or payers with the click of a check box.

For sophisticated users who wish to create their own unique edits, an “edit wizard” guides users through the process of creating edits based on a set of parameters that trigger customized messages.

Improve Compliance With Instructive Reports

Detailed reports capture and present all the information necessary to make coding corrections before submitting actual claims. The split-file feature separates good claims, which are ready to submit immediately, from claims that must be corrected.

Reports fully explain the error logic in easy-to-understand terms, explaining the appropriate corrective action when possible. Also, reports can be saved as compliance documentation. Because end users have everything they need to make coding corrections, our software also serves as an educational tool, promoting yet another important compliance requirement.