What Can a Clinical Coding Edit Solution Do for You?

We have talked about the reasons for claims denials before. Let’s now talk about their impact.

Due to either incorrect or missing information, a practice experiences on average almost 5 claim denials per week per full-time physician. If you consider that the average amount of time spent on a resubmission is about 16 minutes, that equates to about $15 in labor per resubmission and 5 hours of time every month spent just on resubmissions. These five denials per week add up to about 20 denials per month, 5 of which are written off, which ultimately results in over $5,000 lost annually per physician. And this is just talking about claim denials related to the claims data – there are many other reasons why you may experience denials.

In a word, the impact of denied claims is big.

Figuring out how to minimize denials due to incomplete or incorrect claims data without sacrificing efficiency can be tough. The good news is that there are solutions. Sometimes called clinical edit solutions or advanced coding solutions or claim scrubbers, these tools can be offered through your practice management system or clearinghouse and can greatly assist your practice in spotting errors on your claims prior to submission without creating a bunch of additional work for your staff. In addition to the library of edits most clearinghouses incorporate in their own systems, good front-end tools house libraries of tens of thousands of edits related to deeper-level data – medical necessity, Correct Coding Initiative, modifier edits, and edits for age and/or gender to name a few categories.

These tools analyze diagnoses, charges, modifiers and insurance-specific identifiers and then provide alerts to the problems that will ultimately deny those claims. Staff can quickly correct issues and, in some practice management and EHR systems, administrators can even create their own custom rules that automatically correct common mistakes. The result? Instant visibility into CPT or HCSPCS codes that are no longer valid, missing ages and genders, missing modifiers for necessary CPT codes, and additional codes needed to support a claim’s primary diagnosis codes, all without dedicated a staff person’s time to reading each claim one-by-one. You save time, you save money, and you improve your revenue cycle along the way.

 If you find your practice struggling with managing denials, or consuming valuable staff time necessary to review and resubmit your denials, a clinical coding edit solution may be for you. 

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