Clean Claims Task Force

Wednesday, January 01, 2014 11:34 AM
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Final set of rules to be submitted in early 2014

Marilyn Rissmiller, Senior Director, Health Care Financing

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Colorado enacted the Medical Clean Claims Transparency and Uniformity Act in 2010. It was designed to save the state millions of dollars a year with the understanding that payers and providers will face less administrative redundancy and waste, which can be redirected toward reducing the actual cost of care.

CMS strongly supported the act and actively participates in the resulting 28-member task force, which also comprises representatives from major payers, claims software vendors, the Colorado Medical Group Management Association, the American Medical Association, local physician billing personnel and the State of Colorado. The group is working to identify and develop a standardized set of health care claim edits and payment rules to process medical claims. The work of the task force is guided by principles that focus on administrative simplification: consistency, standardization, transparency and improved system efficiency.

The task force submitted a report to the General Assembly in January 2013, which resulted in a bill sponsored by Sen. Irene Aguilar, MD, and Rep. Sue Schafer concerning the development of standardized rules in processing medical claims and extending the deadlines and authorizing appropriation of state funds for the development of a set of rules.

The task force presented its final set of rules at the beginning of December 2013 and accepted public comments through Jan. 6, 2014. There were five in this set.

  1. Bundled: identifies when certain services and supplies are considered part of the overall care and should not be billed separately.
  2. Multiple E/Ms on the same day: identifies when multiple evaluation and management services are billed on the same day by the same provider. With exceptions and the appropriate modifier, only one E/M may be eligible.
  3. Procedure to modifier validation: identifies when a modifier is inappropriately reported with a procedure code.
  4. Rebundled: identifies incorrect coding when two or more codes submitted together are better described by a single code or series of codes, which ensures accurate coding with the most comprehensive code that best describes the service performed.
  5. Effect of CPT and HCPCS modifiers on edits: identifies those modifiers that have an effect on claims processing.

All stakeholders – especially specialty societies in Colorado and nationally – were invited to be engaged throughout the entire process and we are grateful for all comments. Aggregated comments were posted online and considered by the task force for inclusion in the following set of rules. Sixteen rules have already completed the rule development in its entirety. The process requires consensus on the initial draft, distribution for public review, second review by the task force, official response to comments and final consensus.

The final rules will be submitted to the General Assembly in early 2015 and used by all payers and providers in Colorado by Jan. 1, 2016. Colorado leads the nation in efforts to standardize claim edits and payment rules across private payers. For more information, go to

Posted in: Colorado Medicine | Practice Management | Coding and Billing


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