How to enhance edits to achieve clean claims.

The effective use of edits within a healthcare organization’s billing system may permit such organizations to not only identify documentation, billing, and coding issues to address, but also facilitate achieving an improved clean claim rate.

A clean claim is one that meets the specifications of a payer, accurately represents services provided, does not result in a rejection, and facilitates timely payment. One facet of achieving a clean claim is edit management. 

Edits usually are built into billing systems prior to claims being processed through the scrubber. Edits are designed to trigger rules and possible adjustments to each claim within the claim system.

The basis for many of edits includes the National Correct Coding Initiative (NCCI), outpatient coding edits (OCEs), mismatches of charges to the codes assigned by coders, payer-specific requirements (such as an HCPCS code being used instead of a CPT code), medically unlikely edits, and provider-driven rules.  Most of these edits can be established proactively in the billing system or electronic health record (EHR). Additionally, when we see claims being rejected by a clearinghouse and/or payer, we need to study the reasons why to determine if there are other opportunities for edits. 

Our focus needs to center on both rejections triggered by claim processing and coding guideline rules, as well as those that may be payer-specific and payer-driven rules.   

An addressable example of a reason for a rejected claim could be when the gender is inconsistent with the procedure: for example, a male procedure performed on a female patient. In this situation, the edits we need should check gender-related conditions against the demographic information of the patient. There may be age-related codes that require edits as well. An example of a common payer rejection is when a procedure is approved for a physician office but carried out as an inpatient service in a hospital. In this case, the payer may reject a claim for the reason of the mismatch on the authorization. In this situation, we would want to build an edit in the surgery scheduling system or EHR, if possible, to catch the patient status mismatch prior to conducting the surgery. Finally, a payer-specific rejection may occur when a payer requires a claim to be submitted with an HCPCS code at a time when there is an approved CPT-4 code that is accepted by all other payers.

Some rejections may identify the need to add a code. These rejections need to be researched to determine if the additional code must be added every time the partner code appears on the claim. In this case, the edit rule would be designed in such a way that if the partner code appears and the additional code does not, the system will assign the code.

Both system- and payer-driven proposed edit rules must be researched thoroughly, judiciously used, and tested before they are implemented. I mention the judicious use because there may be suggestions to automatically assign codes, modifiers, or possibly charges without appropriate validation by a coding professional or charge entry specialist. This is where health information management (HIM) must take a stand – and, when necessary, call upon the compliance officer to reinforce resistance.

Additionally, it is imperative that the frequency of triggered edits is monitored and measured. When edits continue to be triggered, education and re-education must occur, and reports of offending departments must be distributed and reviewed at the revenue cycle and other committee meetings. It’s the tracking and trending that will help enhance the clean claim rate. Without the squeaky wheel getting the grease, the clean claim rate will continue to languish.

As revenue cycle leaders, we have a responsibility to ensure that claim-related actions are compliant with charging and coding guidelines and supported by the documentation in the record. Quick and easy measures may not be the best fix. 

Our goal is to ensure that the revenue we receive is that to which we’re entitled.

Revenue integrity is as important as documentation integrity, and who better than a HIM professional to ensure both are achieved?


Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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