Use Caution with Claim Scrubbers

Use Caution with Claim Scrubbers

By Dorothy Steed, CPC-H, CPCO, CPMA, CPC-I, CEMC, CFPC

Electronic billing systems usually have built-in claim scrubbers to prompt billers to enter claim information. Providers should not assume that the scrubber will eliminate the need for quality billing skills. The biller should be well trained and knowledgeable about multiple payer requirements. Regardless of whether the system prompts the biller for certain entries, the biller should be able to recognize certain claims requirements, such as number of units, appropriate modifier usage, and suitable matches of information.

Common Problem Areas to Watch

  • Ineffective modifier reporting can result from lack of understanding about payer processing edits. For example, when two modifiers are required, some payers allow reporting of the service code one time, with both modifiers on the same line. Other payers may want the service code reported on two separate lines with specific modifier appended to each line.
  • Poor understanding of National Correct Coding Initiative (CCI) edits may be another problem for billers lacking fundamental experience. An effective claim scrubber should prompt for review of the services and whether both should be reported—but the biller will need to be able to determine whether there is an unbundling issue or whether both can be reported with a correct modifier.
  • There may be situations when two separate errors override each other and the claim scrubber may fail to edit for either problem. A-well trained biller should be able to review the information on the claim and determine whether it is complete and error free. Providers should never remove multiple edits from the claim scrubber to “get claims out the door.” Edits will occur in the payer’s processing system and result in multiple claims rejections.
  • Sometimes, the claim scrubber will flag for information changes when the claim is correct. These issues should be resolved with the billing software vendor.

Successful resolution of rejected claims requires that the biller understands the reasons for the rejection, and knows the necessary steps to correct the claim. Staff members that do not possess adequate billing and coding knowledge are not likely to be able to resolve problems within the payer time limit for correction and/or appeal. Additionally, repeat submission of erroneous information may be deemed billing abuse and trigger a payer audit.

The bottom line: You may use claims scrubbers for their intended purpose, as a tool to provide assistance in submitting clean claims. Understand that they are not infallible and are not to be substituted for adequate billing and coding skills and strong physician documentation. “The system did not flag for an error” is not an acceptable argument in a payer audit.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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