Clinical Editing

Clinical editing, a critical part of identifying and eliminating inappropriate payments, is a process of reviewing bills for appropriate coding and reimbursement andrestricts how a procedure can be reimbursed. Components of clinical editing may go beyond those noted in the MCO’s medical bill editing criteria package below.  For example, medical necessityshould determine reimbursement eligibility for the physical medicine treatments or modalities, not the number of the modalities. Three modalities might be medically necessary for one injured worker, but only one for another. The provider reports what was done and the MCO determines if reimbursement is appropriate for the allowed conditions in the claim.

 

The MCO must supply the rationale behind the editing to the provider and identify the software vendor upon request.

 

MCOs are not required to follow The Centers for Medicare and Medicaid Services (CMS) or any other specific designated medical editing criteria guidelines. However, MCOs are required to have a nationally recognized, medical bill editing criteria package and shall supply the rationale behind the editing to the provider and identify the software vendor. MCOs must update their clinical editing software yearly to include CPT additions, changes and deletions The MCO’s clinical editing shall contain but is not limited to the following.