Medical Policy
Effective Date:08/04/2010 Title:Clinical Edits
Revision Date: Document:BI270:00
CPT Code(s):None
Public Statement

Effective Date: This policy will apply to all services performed on or after the above effective date.

  1. QualChoice uses a program developed by McKesson called Claim Check as a tool to help with the clinical editing of claims.
  2. Clinical editing 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 deviating from practice standards, and diagnoses or procedures that may be invalid for the age and/or gender of the patient.
Medical Statement
  1. Review of code usage in billing for medical services is a standard industry practice. This action 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 degree 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), McKesson’s proprietary edits, American Association of Orthopaedic Surgeons (AAOS) edits, and other medical society determinations.
  3.  Clinical edits are applied to all claims submitted by professionals, in and out of network, and for all lines of business.
  4. QualChoice 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 appropriate review by certified medical coders.
  5.  A multi-departmental, interdisciplinary oversight committee will make decisions regarding customization of edits based on evidence-based documentation.
Limits

1.    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.

2.    QualChoice will consider individual claim exceptions to clinical edits on reconsideration when submitted clinical documentation supports that action.  
Reference
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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.