Step to Editing Only Process

CMSPricer offers a service to provide editing only. This process is an inexpensive solution that analyzes a claim and identifies any edits, if needed. We will only edit the claim in this situation and not re-price it. The edit-only approach is typically a fast and scalable API interface. Our internal technical experts work with our clients to design and implement a workflow that meets the client’s specifications. We report back to our clients the analytics behind each claim and edits that fired against the algorithms in production. Editing ensures the claim is clean and paid accordingly via CMS Medicare policy. The same is true for facility claims with multiple specialists submitting charges on one hospital claim. The claim edits ensure accuracy and limit over or under-payments. Typically, these claims without edits may be over-paid according to CMS Medicare policy rate schedules. We also can customize configurations to switch “on/off” specific edits, if desired. Configuration forms, part of the CMSPricer portal, provide an easy, user-friendly dashboard that the client can self-manage. Claims for editing can also be self-loaded via an excel batch method, whereas the client imports the claims for editing and easily exports the claim results, all self-services. This entire process can be performed in a matter of minutes and is offered 24/7 based on the client’s needs and timeline.

The following are the typical edits that we process:

Claim Edits:

  • Diagnosis Code Validation
  • Local Coverage Determination (LCD)
  • National Coverage Determination (NCD)
  • Age Edits
  • Gender Edits
  • Outpatient Code Edits (IOCE)
  • Medically Unlikely Edits (MUE)
  • Correct Code Initiative (NCCI)
  • CPT Edits
  • RVU Edits
  • Modifier Edits
  • Advance Benefits Notice of Non-Coverage (ABN)

Step 1 - Simply configure the edits “on/off” and CMSPricer will edit the claim accordingly. We also have clients that run an API for easy and automatic feeds back into your process workflows.