|
|
ClaimEditor Edit Hierarchy
Type 1: EDI File Structure Syntax – Check for the presence
of required X12 data segments. Verify reported data segments are
X12 compliant. Validate data element attributes (e.g. maximum
element lengths are not exceeded; date fields are properly
formatted, etc.) with X12 rules.
Type 2: HIPAA-Specific Syntax – Check reported data
segments, elements, codes and qualifiers for compliance with
837-specific implementation guidelines. This also includes
checking for intra-segment situational data elements (e.g. if
element A is populated, then element B must also be populated).
Type 3: Balancing Amounts – Check each claim for balanced
field totals where appropriate (e.g. the total claim amount must
equal the sum of all line item amounts).
Type 4: Situational data – This includes the validation of
situational data fields relative to other data reported in the
claim. Many data segments and elements are required only under
certain conditions (e.g. an accident date must be reported if an
accident code is reported; the accident state must be reported
if an auto accident is reported; a revenue code requires an
admitting diagnosis or patient reason for visit, etc.).
Type 5: External code sets – Validate all external code sets
such as CPT/HCPCS/CDT codes, place of service codes, ICD9
diagnosis and procedure codes, DRGs, revenue codes, occurrence
codes, treatment codes, condition codes, value codes, patient
status codes, taxonomy codes, zip codes, state-zip code
combinations, et al. Validation includes testing for appropriate
usage within the claim and for coding guidelines that apply to
the specific code set. Some examples: modifiers, diagnosis and
place of service codes must be appropriate for procedures;
procedure and diagnosis codes must be valid for the reported
dates of service; correct use of add-on procedure codes;
procedure and diagnosis codes appropriate for the patient’s age
and gender; Correct Coding Initiative (CCI) compliance;
occurrence codes are appropriate for the type of bill; diagnoses
are coded to the proper level of specificity; the reported
primary diagnosis is a valid primary diagnosis, etc.
Type 6: Lines of service – Check for requirements that apply
only to specific lines of business/service. Specialized services
such as ambulance, chiropractic, podiatry, home health, skilled
nursing facilities, durable medical equipment (DME), etc. have
specific claim editing requirements in addition to those
mentioned above (e.g. ambulance service claims must always
include ambulance transport information).
Type 7: Payor specific – Check for payor-specific published
and non-published requirements that, if not met, can lead to
claim rejections prior to adjudication and suspended or denied
payments after adjudication. This includes validating procedure
and diagnosis codes with published LMRPs/LCDs.
|
|
|
