The RCxRules Blog

What Are Custom Claim Edits and Why Are They Important?

What Are Custom Claim Edits and Why Are They Important?

What are claim edits?

According to Healthcare Innovation, healthcare claims editing is a step in the claims payment cycle that involves verifying that physician-submitted bills are coded correctly.

Large medical groups must contend with claims that are high in volume and complexity. In many cases, these organizations rely on billers and coders to manually review claims for accuracy. Alternatively, organizations can leverage technology—specifically automated claims editing software—to ensure a clean claim rate. While there are universal or standard claim edits such as National Correct Coding Initiative (NCCI) Edits, Global Edits, and Correct Coding or ICD-10-CM Edits, these types of edits do not cover all requirements for large medical groups. Additional requirements include payer, specialty, provider, or location-specific edits.

In working with over 25,000 providers, we’ve learned through experience that no two organizations are alike. The way information flows, the systems that are used, payer contracts, specialties, patient mix, staff, and myriad other factors make every medical group unique. This makes standardizing the revenue cycle process extremely complex—so customization in claims edits is a necessity.

For example, let’s say a payer requires office visit charges and lab charges to be on the same claim. However, a medical group has lab charges coming from their lab system and office visit charges coming from their EMR. Oftentimes, the lab charges do not come over to the RCM system for 24-48 hours after the office visit charge comes over. A standard claim edit would not be able to help with this scenario. That leaves the group with two options: to manually review all lab charges and search for corresponding office visits and then adjust the claim, or to use the two custom edits below to automate the process:

  • Edit 1: Hold all office visit charges for a period of 24-48 hours and wait to see if a lab charge will come over from the lab system.

  • Edit 2: Search for lab charges unique to the patient and for the same date of service of an office visit. If one is found, move the lab charge over to the same claim as the office visit and combine everything into one claim.

If a lab charge does not come over within 48 hours, the first edit assumes a lab charge is not coming and releases the office visit charge as a standalone charge into the RCM system.

With the right technology, such as the RCxRules Revenue Cycle Rules Engine, the ability to create custom claim edits—or as we call them, custom rules—is limitless. Our customers each implement hundreds of custom rules and continuously create new ones to meet their everchanging requirements. Other examples of custom rules can be seen here.

The Revenue Cycle Rules Engine works by automating the review of charges against standard and custom claim edits to ensure the most accurate charges are sent to the RCM system. Only if a rule fails will manual intervention be needed. To create the custom edits, we work with you to understand your payers and revenue cycle challenges, then help you to create rules that reduce manual effort and human error. The billing and coding team also has the ability to create their own custom rules within the software.

If your organization wrestles with a specific billing or coding scenario, we’d love to hear about it. Set up a 15-minute meeting—we’re confident we can help!

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