Clinical editing software update

First phase complete

If you are not already aware, BWC has acquired the MedStat Group Inc.’s Thomson Healthcare clinical editing software package. The software will ensure a consistent and well-defined process for assessing provider billing.

The Thomson Healthcare clinical editing does not replace the clinical editing software managed care organizations (MCOs) use. Instead, it provides a second-level review. This will create a consistent and standardized approach to the screening and reimbursement of provider medical bills.

We will install edits to our payment system in multiple phases. We implemented phase I in August 2008. We implemented six selected edits in that phase. However, we treated the edit results as being as informational only. If you received a message resulting from one of the edits, you would've noticed the edit did not result in a denial of the charge in question.

Effective Oct. 7, 2008, those edits will actively deny. The system will require the provider to submit appropriate documentation for reconsideration of the denial. The assigned MCO will handle all appeals.

Here is a list of the edits included in phase I.

• Inappropriate assistant surgeon - Identifies procedures that do not warrant payment for an assistant surgeon
  EOB 407 – Payment is denied as this procedure does not warrant an assistant surgeon.
• Surgical global fee period - Identifies separately billed visits or procedures billed by the operative provider with a related diagnosis that are part of the surgical global fee package
  EOB 408 – Payment is denied as this is considered to be part of a global fee.
• New patient code frequency - Identifies inappropriately billed new patient codes
  EOB 409 – Payment is denied because history shows a previously reimbursed visit with this provider within the past three years and therefore does not meet AMA “new patient” definition.
• Post operative care by non-operating provider - Identifies post-operative care provided by a non-operative provider within the same global period of the surgery for a related diagnosis
  EOB 410 – Payment is denied as the office/hospital visit falls within the post-surgical follow-up period.
• Pre-operative care by non-operating provider - Identifies pre-operative care provided by a non-operative provider within the same global period of the surgery for a related diagnosis
  EOB 411 – Payment is denied as the office/hospital visit falls within the pre-operative global period.
• Chemistry lab unbundled - Identifies line records containing individual lab codes that can be grouped together and paid under a single laboratory panel code
  EOB 412 – Payment is denied because the set of codes listed should be grouped together under one procedure code as a panel.

If you have questions, please call the medical policy department at 614-752-6723.