Q&A: Claim edit focus areas

Q: What are some of the things you’re currently focusing on for claim edits?

Stephanie Ellis, RN, BSN, COC, CHRI, CRCR, director of revenue performance and audit management, University of Chicago Medicine, Chicago, Illinois: A big piece of the missing puzzle for us is the strengthening of our advance beneficiary notice process. That is part of the work that’s being done this year—not necessarily by my team, but you can imagine how if we already have the ABN, the account will come through with appropriate codes or modifiers to show that the clinician has addressed the medical necessity piece, and we [wouldn’t] need to go into any further research or review for that particular item.

Jennifer Gardiner, CPC, senior director of revenue integrity, University of Maryland Medical System, Baltimore, Maryland: My team is pretty heavily involved with claim edits. We were always hospital based, but in the last year we took on the physician practices as well. Coding now falls under revenue integrity for the professional billing side. It’s a very blended process. With our integration over the last year with taking on our professional services, our organization’s revenue is split about 85% hospital and 15% professional. I think we all went into this integration thinking that’s about how our time was going to be divided. But from a time perspective, my team is now spending about 85% on professional billing–related issues and about 15% on hospital.

Editor's note: This Q&A was excerpted from the 2025 State of the Revenue Integrity Industry Report. Interested in more analysis of revenue integrity trends? Check out the recording of our free webinar that aired on June 4!