Step to Editing Only Process

CMSPricer provides a significant value in increasing first pass through rate for claims when working the revenue cycle. This has become increasing difficult due to coding complexities, changing CMS rules, and regulatory changes. These rules and regulations also continue to change every single day. Due to these changes and regulations, it’s imperative to have an automated method to validate your claims before they are generated and submitted to payers so you can avoid downstream denials and delayed payments like the CMSPricer editing solution which is fully automated via API.

What do these edits entail?

  • Professional (CMS 1500) and Institutional (UB04) CMS rules
  • Diagnosis Code Validation
  • Local Coverage Determination (LCD)
  • National Coverage Determination (NCD)
  • Age Edits
  • Age Edits
  • Outpatient Code Edits (IOCE)
  • Medically Unlikely Edits (MUE)
  • Correct Code Initiative (NCCI)
  • CPT and RVU Edits
  • Modifier Edits
  • Advance Beneficiary Notice of Non-Coverage (ABN)

How this helps our clients:

  • Avoid redundant work around rebilling erroneous claims
  • Reduce days in A/R
  • Increasing correct coding compliance
  • Identify and remedy medical necessity issues before claim submission
  • Receive real time information on identified errors

Results of using CMSPricer edits include:

  • Reduction in denials
  • Identification of missed revenue opportunities
  • Clean claim/first past submission rate of >98%
  • Speed to revenue and reduced days in AR: any rejections are instantly identified prior to being sent to your EDI clearinghouse, saving you an average of 24 days of waiting for rejections and an opportunity to make corrections
  • Decreasing cost: average cost of re-working a rejected professional claim ranges from $10- $25
  • Automatically updated edits built right into your billing system: no need to chase down CMS changes, get familiar with editing rules, coding initiatives, etc. All updates pushed automatically and updated via API

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.