How to Override Published Edits in Medical Billing - dummies

How to Override Published Edits in Medical Billing

As the coder for medical billing, you can override — or bypass — a published edit in the software, if you know how. The most obvious way to bypass a published edit is to assign a modifier to a code. This modifier gives the payer more information about the procedure in question.

Modifiers indicate when a procedure has been altered from its published description and should be reimbursed accordingly. They may indicate that a normally bundled procedure was actually separate or that a procedure required additional time and work by the physician or required assistance of a co-surgeon or assistant surgeon among other things.

In some circumstances, you can’t use a modifier, even though you can clearly see that the provider performed extra work. Iif you’re dealing with a commercial payer, you may be able to convince the payer to allow the additional procedures. Keep in mind, though, that if these payers base their argument on edits found in their own claim editing software and the edit says “no,” then the answer is “no.”

Payers use different claim-editing programs that may differ from the NCCI edits and can be frustrating to providers. Usually the payer contracts identify which claims editing software they use. Some payers use more than one type of editing software and apply the one that allows them to pay the least. This situation is frustrating for providers, and if it’s in the contract, it can be very hard to challenge successfully.