Claim editing software for greater accuracy and enhanced revenue
Claim editor or “claim scrubber” software is rapidly becoming a standard part of medical billing software. But only ClaimStaker verifies both professional and institutional claims using the most comprehensive medical necessity database.

ClaimStaker gives both physician organizations and hospitals access to essentially the same technology payers use. Using it prior to claims submission, ClaimStaker can improve claim validity, improve cash flow and demonstrate clinical defensibility.

LCD/NCD data provides coverage rules for a fraction of all CPT® codes. ClaimStaker adds a proprietary clinical medical necessity database to cover virtually all possible ICD-9/CPT code combinations. Constantly improved over the course of more than 20 years, our database yields a depth of edits no one can match.

ClaimStaker functions

Diagnosis code edits

• ICD-9 validity, including ultimate specificity, secondary code and patient gender/age • E-codes • V-codes

Procedure code edits

• CPT validity, including patient gender and age • Correct Coding Initiative (CCI) bundling • HCPCS validity •  RVU sequencing • Modifier usage • Global fee periods

Outpatient Prospective Payment System (OPPS) edits

• Outpatient Code Editor (OCE) validation • Revenue/HCPCS code combinations • Condition Code, Occurrence Code and Value Code checks

Medical necessity edits

• Part A and Part B LCD/NCD • Proprietary E&M and surgical codes • E&M level of service

Claim-level technical edits

• Policy number and group number validity • NPI (provider number) validity • Accident indicators / date accuracy • Location of service appropriateness • Charge versus allowance analysis • Overall proper claim completion

File format edits

• ANSI 837 EDI claim file format verification • Situational segment and data element evaluation • Maximum/minimum field lengths • Proper qualifier usage • Data content accuracy

ClaimStaker features
ClaimStaker accepts claim files created by most hospital billing and practice management systems. Though end users may maintain their existing billing software, no duplicate data entry is necessary.

E&M edits
A unique feature, ClaimStaker applies an acuity level to each ICD-9 code in a claim. With it, you can more reliably avoid the risk of over-coding and prevent under-coding for E&M services.

Customized edits
ClaimStaker’s ease of customization and ability to accommodate unusual insurance rules truly set it apart. And each standard edit in ClaimStaker can be enabled or disabled for specific claim types or payers.

For advanced users, an “edit wizard” guides you through creating edits based on a set of parameters that trigger customized messages.

Detailed, instructive reports
ClaimStaker’s detailed reports capture and present all the information necessary to make coding corrections before submitting actual claims. The split file feature in ClaimStaker separates good claims, which are ready to submit immediately, from claims that must be corrected.

Software developer interface or integration
Whether it’s a quick interface or in-depth integration, Alpha II works closely with developer partners to ensure efficient, effective and appropriate access to ClaimStaker features. Software developers can interface ClaimStaker’s advanced functionality to their practice management and hospital billing systems with minimal workflow process modifications. For tighter application integration, you can embed the ClaimStaker edit process to create a work queue displayed within the host application’s user interface.

 

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