February 2006 Newsletter
Understanding Xpeditor Edits
As the Quadax EDI Services Department has grown, so too has the level of scrutiny being applied to what we refer to as edits—the value-added aspect of our Xpeditor product that determines whether the claim you are passing to us contains data that is valid and complete enough to pass the adjudication process of the payer to which it is being sent.
With 33 years of experience in the business, it’s often assumed that we would know everything there is to know about claims and be able to identify unreasonableness when it’s encountered. The fact is, just like you, we have to continually monitor the industry for changes and decide if there is an impact to us or our clients. Occasionally we miss one, and as the advent of specialization works to complicate things, these occurrences are highlighted when we take on a new account with needs we have not yet encountered. Nonetheless, we strive to re-address these in a timely and professional manner.
Replacing an existing EDI vendor at a client brings an additional complexity to the situation, one being the definition of terms, the other being the previous vendor’s explanation of a rejection compared to how Quadax conveys the message. This is especially true when it comes to the verbiage used to describe an error, specifically, when the presence of data in one field requires the inclusion of something in another field. For example, while a former vendor’s system would point to a certain revenue code and indicate that an occurrence code is required, the same claim dropped into Xpeditor would result in an error being raised that indicated a value code is missing. Both errors are technically correct because the two fields are complementary, and neither is wrong—it’s simply a matter of unlearning one system to learn the other.
Quadax Terminology
Three areas that are commonly interpreted as interchangeable terms are:
Compliance. Other vendors have used this term to blanket cover all aspects of claim processing, sometimes taking this as far as using it to decide if a customer’s special request will be coded. Quadax takes a different approach to this term, applying “compliance” only to the acceptability of converting the claim into the outgoing format (i.e. HIPAA compliance). For instance, limiting the passage of E codes to only those entered in UB block 77 to enable translation to the HI segment with a BN qualifier in the 837, or requiring that complete COB data be supplied so all loops and segments are created when passed in the transaction.
Proper Billing. This term refers to the review of a claim to determine its functional acceptability; will the submission of this claim result in a positive adjudication? It may not contain all of the charges that it could, but payment will be made by the third party. This is the primary focus of our efforts as they relate to the maintenance, development, and application of edits upon claims. There is no benefit to Quadax to stop claims that would otherwise pay, regardless of whether additional procedures could or should have been coded along with the other charges. Items such as revenue centers, which were not listed but are generally billed in tandem with another, would not result in our stoppage of the claim. These are better left to the discretion of the client or a third party whose focus is on the maximization of revenue.
Revenue Enhancement. Identifying items that are normally charged in conjunction with another procedure is often reliant upon the mission focus of a facility. The management structure of one organization may be such that a high level of attention to these details is a primary directive, whereas another facility is consumed with just getting the bills out. The former approach has multiple remedies, such as custom edits, XpressBiller rules, and third-party applications such as Wellington’s APC product. Our approach to allowing claims to pass as long as they can be adjudicated addresses the latter approach effectively and reduces stress for both entities.
Claim Submission
When a biller is confronted with an edit that appears to be invalid and determines that the claim should be allowed to flow on to the payer, or accepts that the claim will fail but needs to have it submitted because of timely filing or coverage issues, she has the option to "Force" it through the edit and send it to the payer. There are instances, however, where some errors must be deemed Non-Forcible (NF) because allowing a claim to be written to the 837 with them would knowingly result in the entire file being rejected. In that scenario, all of our clients would be adversely affected.
Some of our newer clients expressed a concern that Quadax did not code edits around the generally accepted principals of the Outpatient Code Editor (OCE). For the most part, this was not the case but was another example of where our error description did not stand out as being raised as a result of an OCE-related item. To satisfy these concerns, we have developed a separate set of table-driven edits using error codes that begin with “UOCEx” and an error description beginning with the words “OCE conflict.”
A similar tactic was used with the implementation of the Correct Coding Initiative (CCI), so that error codes are prefaced with “UCCIx” and error descriptions with “CCI conflict.”
When Local Medical Review Policies (LMRP) were introduced, followed by National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), we chose to begin the error description with the appropriate designation followed by the reference number. Additionally, we also provide an optional link to a facsimile of the transmittal to allow you to examine our rationale for raising the error.
Clients have multiple methods to stop claims when Xpeditor does not raise an error, based on factors inherent to their facility. If you desire to have Quadax develop a custom convert (change data) or a custom edit (raise an error), you can submit a request through our ASP Portal. Bear in mind, however, that fees are associated with this action. Alternatively, clients who desire to retain control over these items and do not want to incur an expense can use the XpressBiller Claim Correction System. This unique suite of tools allows our clients to program Xpeditor to automatically correct a claim based on the error message (Auto Correct Rules), change data (Convert Rules), raise errors (Edit Rules), or modify claims that fail for LCD or NCD reasons (Medical Necessity Rules).
Sources of Information
Two organizations within Quadax meet on a monthly basis to review industry changes and new requirements. The Insurance Committee focuses primarily on those items associated with professional fee billing, while the UB Edit Group concentrates on factors involved in billing facility claims. Both of these meetings decide how edits should be coded as a result of new regulations, client concerns, payer guidelines, etc. Additionally, they conduct reviews of payer web sites, newsletters, and other communications as they relate to the billing of these claims. These meetings are summarized in our newsletter Connections, which is distributed monthly via email. If you are not currently receiving this newsletter, please send an email request to EDISupport@Quadax.com, and we’d be happy to add you to our growing list of subscribers.
Sending claims to payers includes the retrieval of reports that designate the acceptance or rejection of claims. We report rejected claims through Xpeditor’s tracking technology, and then retrieve the claim from your History database in order to republish it with a code of “Payer Err” for “Payer Error.” These rejections are also compiled into a weekly report that enables us to perform a review for items that should have been identified prior to their submission. This Payer Error Review is continuous and is historically kept at or under 5% of all claims submitted. The majority of the rejections are related to eligibility, or lack thereof. However, from time to time, we identify edits that are added with the next codetable release.
Advanced Capabilities
Working in conjunction with Mediquant, a vendor who supplies software (FirstComply) that determines the need to obtain an ABN, has enabled Xpeditor to provide advanced capabilities. The presence of an acknowledged and signed ABN, which matches the diagnosis and procedures billed on the claim, permits the biller (or Xpeditor) to influence changes to the claim such that the charges can be submitted and the claim properly adjudicated. A number of our clients are taking advantage of this integrated solution and find it to be exceptional.
The Wellington Group is another organization that has found synchronicity with Xpeditor, allowing individual claims to be analyzed for APCs, the payment groups used in the hospital Outpatient Prospective Payment System (OPPS). Wellington’s APC recovery program uses their Ambulatory Claims Editing System to identify when a claim is likely to contain lost APC revenue and is displayed in Xpeditor’s error window. The amount of revenue this process has identified for some of our clients is astounding.
Overall, there is a great deal of effort that goes into the development and maintenance of our edit engine, and there is even more in the works. The creation of a whole new way of managing edits, what we term Transaction Rulez, is under consideration. One objective of which is to enable clients to selectively turn off an edit if it is felt it should not be applied to their claims. These are revolutionary ideas that are still in their infancy, though. In the meantime, we will continue to attend to the matter of edits with all due diligence.
