Edit Maintenance

There are several edit maintenance options available in ClaimStaker. You can

• customize professional claim edits;


• customize professional encounter edits;


• enable and disable MIPS quality measure claim edits;


• enable and disable MIPS quality measure encounter edits; and


• customize institutional claim edits.

Professional claim/encounter edits and institutional claim edits

The Professional Claim, Professional Encounter, and Institutional Edit Maintenance pages allow you to select the professional and institutional edits you wish apply to your claims and encounters during the claim scrubbing process. Edits can be enabled or disabled for all claims, for a certain claim type (Blue Cross/Blue Shield (BC/BS), Tricare, Commercial, Medicaid, Auto, Workers Comp, Medicare, or Medicare Advantage), or for specific payers by a simply selecting/enabling a check box. (Please note: In order to customize a payer's edits, the payer must first be set up as a working payer. See the Working Payer help page.)

MIPS quality claims and encounter edits

The MIPS Quality Measure Claim and MIPS Quality Measure Encounter Edit Maintenance pages allow you to select the MIPS edits you wish to apply to your Medicare claims during the claim scrubbing process. Edits can be enabled or disabled by selecting the check box under the Medicare column for that edit.

All Edit Maintenance pages

Below are descriptions of four of the columns displayed on all Edit Maintenance pages:

1. Edit Number – A unique number assigned to an edit
   The edit number displays in the audit results along with the edit message. Because many edit names and messages are similar, the edit number provides a reliable way to identify a specific edit.


2. Edit Name – The name of the edit
   The Edit Name column displays the names of the edits available for use during the edit configuration process.


3. Edit Category – A code by which the edits are grouped
   The Edit Category column displays the names of all the category codes and enables you to sort edits by type. Descriptions of the different category codes are provided below:
• AUTH – Authorization
• CCI – Correct Coding Initiative (unbundling)
• CONDCODE – Condition code
• CPT/HCPCS – Current Procedural Terminology Code/Health Care Procedure Coding System Code
• DATE – Date
• DEMOG – Demographic data
• E/M – Evaluation and management
• ICD – International Classification of Diseases (diagnosis)
• ID – Identification number
• MCE – Medicare Inpatient Code Editor
• MN-CAID – Medicaid medical necessity
• MN-COMM – Commercial necessity
• MN-LCD – Medical necessity policy from a Medicare local coverage determination policy
• MN-NCD – Medical necessity policy from a Medicare national coverage determination policy
• MN-PROP – Alpha II proprietary medical necessity
• MOD – Modifier
• OCCURCODE – Occurrence code
• OCE – Medicare Outpatient Code Editor
• POS – Place of service
• PROV – Provider
• QM-ASC – Quality measure ambulatory surgery center
• QM-MIPS – Quality measure Merit-based Incentive Payment System
• QM-THERAPY – Quality measure therapy functional reporting
• REIMB – Reimbursement
• REVCODE – Revenue code
• TOB – Type of bill
• UNITS – Units of service
• VALCODE – Value code


4. Edit Severity – Probable action by payer
   The Edit Severity column provides the likely payer action for claims and encounters received for each error type. Definitions of the different edit severities are provided below:
• Actionable – Provides information that may result in the need for further action to be taken prior to finalizing a claim. When an edit with an actionable severity is returned, it is often the case that data other than the data present on the single claim must be reviewed in order to conclude whether or not the claim data should be modified.
• Claim Denied – Indicates the claim will be processed by the payer but includes one or more errors that will cause the entire claim to be unpayable. If a denied claim is resubmitted without an appeal or reconsideration request, it will most likely be considered a duplicate and be denied, and the claim will remain unpaid.
• Claim Returned to Provider – Indicates the claim includes one or more errors that will cause it to be returned as unprocessable. The claim can be resubmitted as a new claim once the errors have been corrected.
• Claim Suspended – Indicates there are one or more edits present that cause the whole claim to be suspended. A claim suspension means that the claim is not returned to the provider but is not processed for payment until the payer decides or obtains further information.
• Delayed Payment – Indicates the claim includes services that are expected to require additional information that cannot be included on the claim, such as medical records. In most instances, the payer will request the additional data and hold the claim for a specified period of time to await the additional data. If the data can be sent as an attachment or faxed to the payer when the claim is submitted, the payment delay can be lessened.
• Informational Message – Provides information specific to CPT/HCPCS codes or otherwise that will assist coders and billers in correcting other edits that trigger on the claim that have a greater severity. For example, on institutional claims, informational edits identify the status indicator assigned to each CPT/HCPCS code, which is helpful in understanding why an OCE edit may have failed.
• Line Item Denied – Indicates the claim will be processed for payment but payment for the line item will be denied. The line item cannot be resubmitted but can be appealed.
• Line Item Rejected – Indicates the overall claim can make it into the payer’s computer system for processing, but the specific line items in question will be rejected due to the lack of adequate information that is required to process payment. The line items can be corrected and resubmitted but cannot be appealed.
• Payer Discretion – Indicates that the claim contains services that may or may not be payable based solely on data that can be included on the claim but that may relate to prior claims or be priced by the payer based on medical review or other requirements. The edit messages that contain a severity of Payer Discretion will usually define the situation.
• Reduced Payment – Indicates the claim data could possibly be formatted differently or include additional information that may result in a higher reimbursement. A payment reduction means that either a line item may be denied totally, a portion of the payment may be applied to a deductible, or a multiple procedure discount may be taken, when if coded differently, a reduction in payment may not occur.
• Reject Claim – Indicates there are one or more edits present that will cause the entire claim to be rejected as unprocessable. Claims that are rejected will not be processed; they do not make it into the payer’s computer system because minimum data requirements are not met. If a claim rejection occurs, it means that the provider can correct and resubmit the claim but cannot appeal the claim rejection.

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