Clean Claims Task Force

Saturday, September 01, 2012 01:18 PM
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Task force seeks physician input on standard set of payment rules, claims edits

Sara Burnett, CMS contributing writer

A Colorado task force is seeking physician input to create a standard set of payment rules and claims edits to help ensure claims are coded, submitted and processed “cleanly” the first time.

This first-of-its-kind project has the potential to free up millions of dollars in administrative burdens that could be reallocated to patient care in Colorado. It also could become a model for the rest of the nation – where the savings could be in the billions of dollars.

But to be successful, the task force needs help from physicians and specialty medical societies.

“The involvement of physicians and their specialty societies will ensure the task force’s final product does not just meet the goal of administrative simplification but is also clinically relevant,” said Barry Keene, co-chair of the task force and the president of KEENE Research & Development.

The Colorado Clean Claims Task Force was created in 2010 under legislation signed into law by then-Gov. Bill Ritter, and with the support of the Colorado Medical Society. It is intended to relieve administrative burdens, improve transparency and reduce health care costs by creating a consistent set of edits and rules that everyone knows and uses. The standard set would be used by all payers in Colorado with the exception of Medicare. (The task force will not address edits used in utilization review or to detect abuse and fraud).

The task force is made up of key personnel from the major private payers and vendors affecting physician health care claims across the country, as well as the American Medical Association, Colorado Medical Society, the state of Colorado and local physician billing personnel. Members meet monthly as a group and more frequently as subcommittees.

The legislation laid out a framework for the group’s work:

“The base set of rules and edits shall be identified through existing national industry sources that are represented by the following: (I) The NCCI; (II) CMS directives, manuals and transmittals; (III) the Medicare Physician Fee Schedule; (IV) the CMS National Clinical Laboratory Fee Schedule; (V) the HCPCS Coding System and directives; (VI) the CPT coding guidelines and conventions; and (VII) national medical specialty society coding guidelines…. The task force shall consider standardizing the following types of edits, without limitation: (A) unbundle; (B) mutually exclusive; (C) multiple procedure reduction; (D) age; (E) gender; (F) maximum frequency per day; (G) global surgery; (H) place of service; (I) type of service; (J) assistant at surgery; (K) co-surgeon; (L) team surgeons; (M) total, professional or technical splits; (N) bilateral procedures; (O) anesthesia services; and (P) the effect of CPT and HCPCS modifiers on these edits as applicable.”

The task force wants to ensure transparency in the method used to establish its complete edit set. In its deliberations, it will work to base the edits on a national source, including special societies when that information is available. Although Medicare is considered a national data set, the Act recognized that there may be gaps and inconsistencies in the edits and rules used by this program and gave the task force the flexibility to look beyond

The task force’s Specialty Society Outreach Committee is working directly with physicians and their specialty societies to identify some of those areas. They are seeking input on any specific coding guidelines, conventions or code pair edits that the specialty societies have developed. Additionally, if there are existing edits or rules in use by Medicare or commercial payers that are of concern, this committee would be the point of contact to insure the task force gives them consideration in its deliberations.

To date, the task force has received direct input from two of the national specialty societies. The American College of Surgeons provided information regarding procedures that generally require the presence of an assistant at surgery, and the American College of Radiology provided documentation in opposition to Medicare’s application of the Multiple Procedure Percentage Reduction (MPPR) formula to the physician component of radiological procedures.

Tammy Banks, director, Practice Management Center & Payment Advocacy with the AMA, is the co-chair of the Specialty Society Outreach Committee and the point of contact for physicians and specialty societies. She has been joined by James Borgstede, MD, a practicing radiologist in Colorado, in an effort to reach out to physicians in Colorado as well as the national specialty societies.

Banks may be contacted via e-mail at or by phone at (312) 464-4792. She will be able to answer questions and/or facilitate a conversation with Dr. Borgstede.

In order for suggestions to be fully considered, the task force asks that you provide a clear statement of the edit and/or rule you would like to address, your recommendation and supporting documentation. The Specialty Society Outreach Committee will review the request and convey the information to the appropriate sub-committee and/or full task force for consideration.

The Colorado Medical Clean Claims Task Force has a website at where you can find more information including the Act, meeting agendas and minutes, and an e-mail contact.


Posted in: Colorado Medicine | Practice Evolution | Administrative Simplification


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