Effective Date: 08/04/2010
Title: Clinical Edits
CPT Code(s): None
This policy will apply to all services performed on or after the above effective
QualChoice uses a program
developed by McKesson called Claim Check as a tool to help with the clinical
editing of claims.
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
- 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.
- 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.
- Clinical edits are applied to all claims submitted by professionals, in and out of network, and for all lines of business.
- 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.
- A multi-departmental, interdisciplinary oversight committee will make decisions regarding customization of edits based on evidence-based documentation.
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.
Clinical edit logic is 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
- 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
- New England Journal of Medicine
- Obstetrics and Gynecology
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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.