Most organizations produce 1,000s of claims a day with hopes they’re compliant and will ensure proper reimbursement. Within those UBs/837Is are claim lines, which are primarily comprised of charging and coding data. The process responsible for creating those claim lines is "Code Integration."
At most organizations, this process is a black box. It happens behind the scenes, and in many cases, doesn’t raise any flags. When it creates billing edits, ownership of those edits are usually unclear. Realistically, the correct owner will depend on the source of the issue, which can range from the charge generation, CDM build, coding, billing, the HCPCS to revenue code crosswalk, system configuration, or possibly payer specific requirements. Working these edits is important, but working together in an organized, systematic manner with all of the impacted parties is critical to prevent further issues and streamline the billing process (see our other article on defining "Revenue Integrity 101").
Apart from the noticeable edits, it’s critical to understand how your claim lines are integrating charges with coding data in regards to your organizational policies, regulatory requirements, and payer contracts. A lack of oversight and understanding with your system's configuration could unknowingly lead to revenue leakage or non-compliant claims.
At The Wilshire Group, our experienced staff and partners understand all of the impacted areas, along with the system configuration. By understanding your organization's charging, coding, and claims' requirements, we can work together to ensure your organization is producing claim lines as expected with maximum efficiency and minimized revenue leakage.