Claims Scrubbing

Sources and review notes

These links support definition-level research and do not establish the regulatory status, safety, or suitability of any product.

CMS identifies ASC X12N 837 Version 5010 as the HIPAA-adopted standard for institutional, professional, and dental health claims and lists the adopted diagnosis and procedure code sets. CMS's National Correct Coding Initiative publishes Medicare and Medicaid program-specific coding policies and edits; Medicare Procedure-to-Procedure edits address code pairs that generally should not be reported together, while Medically Unlikely Edits address units of service and are updated quarterly, with some MUE values not public. These sources cover only part of a complete pre-submission review and do not prove coverage, medical necessity, documentation sufficiency, authorization, payer-contract compliance, coding accuracy, clean-claim status, acceptance, or payment. Teams must apply the transaction, code-set, payer, program, claim-type and date-of-service rules actually in force; preserve source versions and edit identifiers; validate required subscriber, patient, provider, service, diagnosis, procedure, modifier, units, place-of-service, authorization and coordination-of-benefits data; distinguish syntax rejection from coding or coverage risk; prevent unsupported code, modifier or documentation changes; route exceptions to qualified coding and billing staff; and measure false positives, missed errors, overrides, first-pass acceptance, downstream denials and rework by payer.

• Source 1: www.cms.gov/priorities/key-initiatives/burden-reduction/administrative-simplification/transactions/health-care-claim-equivalent-encounter-information
• Source 2: www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits
• Source 3: www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-medically-unlikely-edits-mues