Clinical edits

Page last updated on: 6/22/25

We reimburse facility services according to provider contracts, payment policies and related plan benefits. We often review itemized statements for inpatient hospitalizations to verify services and items are billed appropriately, especially when billed separately.

"Clinical edits" refers to the evaluation of billed codes in relationship to each other for the purpose of identifying unbundled procedures, surgical coding errors, invalid data relationships, patterns of utilization that deviate from practice standards and diagnoses or procedures that may be invalid for the age and/or gender of the patient. We use clinical editing software to perform our clinical edits.

  • We apply clinical edits to all claims submitted by facilities or professionals, in and out of network, for all our medical plans, including Medicaid and Medicare, individual / ACA, group commercial, self-funded and fully funded.
  • We've adopted criteria to align with and follow Medicare guidelines.
  • For more about how clinical edits are determined, see our clinical edits policy information, below.

We base our clinical editing decisions on a combination of Medicare edits such as Medically Unlikely Edits (MUE) or National Correct Coding Initiative (NCCI edits), CMS guidelines, CPT guidelines, ICD-10 guidelines, standard clinical practices and recommendations from medical societies. CMS and NCCI guidelines will take precedence in editing when discrepancies or conflicts exist with recommendations from medical societies.

Providers often assume that if there isn't an NCCI edit for the code combination they have submitted, then we should pay both codes. However, the claim may generate a clinical edit from any of the other sources of our clinical edit database.

  • Review of code usage in billing for medical services is a standard industry practice that supports fair reimbursement for medical services and supplies, accurate data collection, and identification of billing and coding errors.
  • Integrating clinical editing with claims adjudication ensures greater consistency in applying coding rules, greater efficiency, and more timely claims processing.
  • We've developed internal clinical editing processes that balance business needs against the integrity of the application database. This process entails automated application of edits to claims and limited review by certified medical coders.

See our Inpatient and outpatient incidental services and supplies billing policy.

See the edit rationale that was applied to your claims

When you use the Claims Inquiry tool to review your claims, you can see the clinical edit denial reason and review the rationale behind any clinical edits applied to your claims.

Go to Claims Inquiry now

Medicare local coverage determinations (LCDs)

LCDs are different for members under Medicare Part C vs. Original Medicare. To review the Medicare policy that relates to an LCD denial, go to www.cms.gov.

See more about when LCDs apply

Asking for an exception

We'll consider requests for individual claim exceptions to clinical edits. A multi-departmental, interdisciplinary oversight committee makes decisions on whether to customize edits based on evidence provided in the claim documentation.

To ask that we review a clinical edit denial, submit a Level I Appeal with supporting documentation such as operative, procedural or office notes.

 

Payment Integrity code edit relationships and edits are based on guidelines from specific State Medicaid Guidelines, Centers for Medicare and Medicaid Services (CMS), Federal CMS guidelines, AMA and published specialty specific coding rules. Code Edit Rules are based on information received from the National Physician Fee Schedule Relative File (NPFS), the Medically Unlikely Edit table (MUE), the National Correct Coding Initiative (NCCI) files, Local Coverage Determination/National Coverage Determination (LCD/NCD) and State-specific policy manuals and guidelines as specified by a defined set of indicators in the Medicare Physician Fee Schedule Data Base (MPFSDB).