Can medically unlikely edits be loaded into your system? It depends on who your vendors are, and there are many different systems out there— from practice management systems to homegrown systems. Maybe, your physician has a brother that's a computer whiz and he created a system for you for your billing. So, you know, all of these different types of systems exist. Can these edits be loaded into them? Can you have some kind of an edit check where you're checking not only in NCCI edits, the National Correct Coding Initiative edits, you're probably already checking for those. Can you check for these as well? And if so, that's great.
So, the first step is to talk to your IT folks. If you don't have IT folks, then you work directly with your vendors. Talk to your vendors and say, “Hey, can we get the medically unlikely edits loaded into our system so that we can scrub our claims before they go out the door?” If you don't do your own claims submission, maybe you can use clearinghouse, and the potential exists that maybe the clearinghouse can do this for you. If you can't get it loaded in-house in your own system, you know, maybe the clearinghouse can check it for you.
And then you can catch the issues on the front-end before the claims go out, thereby, you can fix the modifiers if need be. You can double check the documentation. Make sure that everything is accurate going out the door. And potentially you'll save yourself a lot of hassle because you accidentally put units of service 780 instead of diagnosis code 780.
Be aware of what types of medically unlikely edits exist for your practice area. So, if you're a hospital and you're doing all kind of claim under the sun, chances are you're not going to be able to memorize all of these. But if you are a physician practice, you do a fairly limited number of types of procedures or even if you are a larger practice, larger facility, go through the listing of the medically unlikely edits and it's in a Excel format. It's pretty easy to do. Also match up to your claims data or your actual billing data. What are your highest volume procedures and match them against the medically unlikely edits and see, you know, how it hashes out. It's kind of the 80/20 rule. You can catch 80% by just looking at the highest volume stuff.
Be aware of what types of medically unlikely edits exist. And then even if you can't get it loaded into your system if you have that awareness, if you're looking for it and you see that something came in that needs to be corrected before the bill goes out the door then you can take a look at that and do that then.
Another option is, if for chance you don't catch things before they go out the door, scrutinize your remittance advice. Make sure you’re not missing any of these denials or RTPs. And sometimes, you know, it could be disguised as something else. It could be just; you think it's another medical necessity denial or whatever.
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