About ClaimStaker

ClaimStaker is a member of the Alpha II family of products. It is a claim scrubber that edits healthcare claims by checking the accuracy of CPT/HCPCS codes, modifiers, ICD diagnosis codes, and more. Because the technology used by ClaimStaker is similar to the technology used by payers to review claims, ClaimStaker helps ensure that claims are accurate before they are filed.

Some edit types included in ClaimStaker are listed below:

Diagnosis code edits

• Diagnosis validity
• Ultimate specificity
• Secondary code suitability
• Patient gender
• Age verification
• External cause codes
• Diagnosis and pointer duplication
• Modifier laterality validity

Procedure code edits

• CPT validity including gender and age
• CCI bundling
• Inpatient and outpatient code editor
• E/M level of service
• HCPCS validity
• RVU sequencing
• Modifier usage
• Global fee periods
• MIPS
• Add-on coding
• Injection editing
• Inpatient/admission validation
• MUE unit validation
• Bilateral service validation
• Revenue/HCPCS code combinations
• Condition code, occurrence code, value code checks

Quality reporting

• MIPS claims
• Functional therapy
• Ambulatory surgical center

Medical necessity edits

• Part A and Part B LCD/NCD
• Links to LCD/NCD policies
• Proprietary (clinically defensible)
• Medicaid
• Commercial

Claim-level technical edits

• NPI validity
• Accident indicators/date accuracy
• Place of service and type of bill appropriateness
• Charge versus allowance analysis
• Overall proper claim completion

File format edits

• ANSI 837 EDI claim-level format verification
• Situational segment and data element evaluation
• Minimum/maximum field lengths
• Proper qualifier usage
• Data content accuracy

In most cases, the electronic data interchange (EDI) files created by your practice management software are the files ClaimStaker will process. ClaimStaker becomes an additional step in the process of routing your claims from your practice management system, through the gateway, and to the payers for processing. Although it may sound like this extra step would delay processing of your claims, the benefit of claims being "clean" when they are received by your payers far outweighs the minimal amount of extra time spent.

If you have questions about ClaimStaker or need assistance, please contact your practice management software vendor.

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