Clinical edits refers to an application that evaluates billed codes in
relationship to each other for the purpose of identifying unbundled
procedures, surgical coding errors, invalid data relationships, patterns of
utilization deviating from practice standards, and diagnoses or procedures
that may be invalid for the age and/or gender of the patient.
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Basis of Clinical Edits
Exceptions
POLICY STATEMENT:
1. Review of code usage in billing for medical services is a standard
industry practice. The practice supports fair reimbursement for medical
services and supplies, accurate data collection, and identification of
billing and coding errors.
2. Integration of clinical editing into claims adjudication facilitates a
higher degrees of consistency in applying coding rules and efficiency in
timely claims processing. Clinical edits are based on CPT coding guidelines,
National Correct Coding Initiative edits (NCCI), CMS guidelines (ex.
follow-up days, assist surgery), Deloitte's proprietary edits (developed for
Trizetto), American Association of Orthopaedic Surgeons (AAOS) edits, and
other medical society determinations.
3. Clinical edits are applied to all claims submitted by facilities or
professionals, in and out of network, and for all lines of business.
4. Priority Health has developed internal processes to assure
administration of clinical edits that balance business needs against the
integrity of the application database. This process entails automated
application of edits on claims and limited review by certified medical
coders.
5. A multi-departmental, interdisciplinary oversight committee will make
decisions regarding customization of edits based on evidence-based
documentation.
Conflicts Between Clinical Editing Sources
In the case of conflict between the edit sources, the hierarchy is as
follows:
- In a conflict between CPT guidelines and NCCI, CPT guidelines prevail.
- In a conflict between NCCI guidelines and AAOS, NCCI guidelines
prevail.
Basis of Clinical
Edits
Clinical edits are based, in part, on:
A. General coding and claim payment references
- Physician's Current Procedural Terminology - American Medical
Association
- National Correct Coding Policy Manual - Centers for Medicare and
Medicaid Services (CMS)
- Medicare Program Revisions to Payment Policies and Adjustments to
Relative Value Units, Health Care Financing Administration
- Relative Value for Physicians - St. Anthony Publishing, Inc.
- Industry newsletters
- Coding and Reimbursement for Physicians - St. Anthony Publishing,
Inc.
- Laboratory and Pathology Report - St. Anthony Publishing, Inc.
- Medicare Part B News - United Communications Group
- CPT Assistant - American Medical Association
- Evidence-Based Medicine - American College of Physicians
B. Clinical practice guidelines
- Clinical Practice Guidelines - Agency for Health Care Policy and
Research (AHCPR)
- Medical Outcomes and Guidelines Sourcebook - Faulkner & Gray,
Inc.
- U.S. Preventive Services Task Force Guide to Clinical Preventive
Services - U.S. Department of Health and Human Services
- Medical Treatment Effectiveness Program (MEDTEP) Practice Analyses -
Agency for Health Care Policy and Research (AHCPR)
- Abstracts of Clinical Care Guidelines - Joint Commission on
Accreditation of Healthcare Organizations
- Diagnostic and Therapeutic Technology Assessment - American Medical
Association
C. Medical journals
- American Journal of Medicine
- American Journal of Obstetrics and Gynecology
- American Journal of Psychiatry
- American Journal of Surgery
- Annals of Internal Medicine
- Annals of Surgery
- Archives of General Psychiatry
- Archives of Internal Medicine
- Archives of Pediatrics and Adolescent Medicine
- Archives of Surgery
- British Medical Journal
- British Journal of Obstetrics and Gynecology
- British Journal of Surgery
- Clinical Pediatrics
- Circulation
- Diabetes Care
- Journal of the American Medical Association
- Journal of the American College of Surgery
- Journal of Internal Medicine
- Journals of Neurology, Neurosurgery and Psychiatry
- Journal of Pediatrics
- Lancet
- New England Journal of Medicine
- Obstetrics and Gynecology
- Pediatrics
- Surgery
Exceptions
Priority Health will consider individual claim exceptions to clinical edits
when the clinical documentation supports that action.
