Claim processing rules are the power behind your cash flow. The tool you use for scrubbing and submitting your claims is only as good as the library of claim edits under the hood that will identify errors before you submit – giving you the opportunity to send clean, error-free claims.
Five essential attributes for the claim edits library that will improve your cash performance are identified in the new e-book by Quadax, Five Must-Haves for Your Claim Edits Library.
The first Must-Have is a comprehensive set of payer-specific billing policy edits, validating claim data for all your claims: Medicare, Medicaid, and commercial. Claims for Medicare or Medicaid managed care products administered by commercial payers may require the application of standard government policies with a twist — the payer’s own unique additions or restrictions. Make sure that each of these rule sets are included in your claim edits library:
For Medicare claims:
Medical necessity policies, local and national. Local Coverage Determinations (LCD) are published by your Medicare Administrative Contractor (MAC), and National Coverage Determinations (NCD), are published by the Center for Medicare & Medicaid Services (CMS). These govern which services are considered medically necessary, and therefore reimbursable, for Medicare beneficiaries based on the diagnosis for which they are being treated. As you know, if a service you’ve provided does not meet Medicare’s medical necessity standards, you may have just provided that service for free (unless you have an Advanced Beneficiary Notice [ABN] signed by the patient prior to the service delivery). Medical necessity policy watchers are presently observing the impact of the 21st Century Cures Act on LCD compliance. The Act, intending to improve transparency in the LCD process, prompted a change to the Medicare Program Integrity Manual. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) codes are moved out of the LCD documents and into billing and policy articles published alongside LCDs in the Medicare Coverage Database. Your claim edits library must be up to date with every policy, every ICD-10-CM code, and every CPT code, whether published in NCDs, LCDs, or separate billing policy articles.
National Correct Coding Initiative (NCCI). CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. Two subsets of NCCI are PTP and MUE.
NCCI Procedure-to-Procedure (PTP) code pair edits prevent improper payment when certain codes are submitted together.
NCCI Medically Unlikely Edits (MUE) indicate the maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary. Corresponding MUE edits are similarly implemented within the Fiscal Intermediary Shared System (FISS) for Part A claims.
Outpatient Code Editor (OCE) edits. This set of rules was developed by CMS to examine outpatient facility claims and identify incorrect and inappropriate coding. The OCE also incorporates NCCI PTP edits. The OCE as used by Medicare contractors also assigns APCs, payment indicators, etc. By applying OCE edits and correcting where necessary prior to transmission, clean claims may be processed much faster, and reimbursed faster, by Medicare.
Coverage Validation edits. These edit routines compare Medicare beneficiary data on claims with the official Medicare data in HETS (the HIPAA Eligibility Transaction System) prior to claim submission to identify any shortcomings to the exact name match needed for claim processing, as well as eligibility, therapy thresholds, max occurrences per year for certain procedures, etc.
For Medicaid claims:
Coverage Validation edits. Similar to coverage validation edits for Medicare, these edit routines query the state Medicaid information systems in real time. They can therefore overcome the biggest challenge when filing Medicaid claims, which is identifying eligibility: verifying coverage at any given point in time; verifying coverage by a Medicaid managed care organization rather than traditional Medicaid, or verifying an identification number. Coverage validation edits running during claim edit routines in the claims management system prior to claim submission can head off eligibility issues that will delay, if not completely obstruct, reimbursement.
Billing policy edits. Specific billing policy rules are common for commercial Medicaid products and vary by payer. These rules are not likely to be published in neat packages, reinforcing the need for diligence and tenacity to discern and confirm the policies and keep them up to date.
Medicaid NCCI. Since 2010, state Medicaid programs have been required to incorporate elements of NCCI into their claims processing systems: PTP and MUE edits for practitioner and ambulatory surgical center (ASC) claims; PTP and MUE edits for outpatient hospital services including emergency department (ED), observation care, and outpatient hospital laboratory services; and MUE edits for durable medical equipment (DME) billed by providers. In 2012, PTP edits for DME were added to the mix. The Medicaid NCCI is slightly different from the Medicare NCCI manual and is therefore maintained separately.
For Commercial claims, including Blues:
Reimbursement Policies. Policies that may be considered the counterpart to Medicare’s NCD and LCD are published by commercial payers to provide guidance in interpreting the payer’s benefit plans, without addressing every aspect of a reimbursement situation. Policies may be applicable by product, by treatment setting, by state, or they may be blanket policies covering all of the payer’s products to one degree or another.
Commercial application of NCCI. Many commercial payers take advantage of NCCI rules, or a subset of them, in their own claim processing routines.
Claim edits libraries are not all the same. Quadax clients have an edge when it comes to claim processing because of the Quadax EDG: the Edits & Documentation Group. The work of the EDG differentiates Quadax as the leader in claim editing because of its diligence to provide each of the five claim edits library essentials discussed in the free e-book, “Five Must-Haves for Your Claim Edits Library.” Request a copy today to read about the other four Must-Haves and learn more about the Quadax EDG.
Keep your cash flow engine running at peak efficiency and optimal performance with the powerful claim edits library of Xpeditor, diligently maintained by the Quadax EDG!