Revenue Cycle Analytics - ICD-9, ICD-10/CPT/HCPCS Rules Engine

Prevalent Healthcare Analytics solution provides a wide variety of "real time" edits as well as vertical business intelligence on your clinical and medical billing databases.    Many times we find the issues occur due to technical failures in the interoperability of disparate systems found in a healthcare provider organization.   Pharmacy, LIS, PACS, Materials Management and EHR solutions maintain seperate databases and then combine data  at the revenue cycle process.   Even if all data was collected and entered correctly, we find in a large variety of circumstances these issues make their way onto the final bill.  

Is this simply "claim scrubbing"?   The answer is a resounding "no" to that question.   We have tried many claim scrubbers over the years and while most of them have some merit,  the methodology lacked the ability to truly vet the accuracy of the data.   Since there is no single resource to check against demographics, insurance subscriber, medical necessity, billing, coding and continually changing  payer rules we had to design our system differently from the beginning.  Because Prevalent quickly imports the data into its database it can use multiple resources simultaneously to not only determine if the data exists (as most scrubbers will verify) but if that data is correct as of the the time of service for this patient/claim.  

  • Medical Necessity Validation

    Our rules engine with validate medical necessity and determine if the procedure performed is valid for that specific diagnosis based on Medicare and Private Payer rules.

  • ABN Verification

    Determines whether advanced beneficiary notice (ABN) is required at time of service

  • Correct Coding Initiative Validation

    Is the CCI Valid, does it require an edit or modifier and is that modifier valid in this circumstance.

    Determines whether CPT1 and CPT2 are typically billed together and whether relevant rocedures should be billed as single code replacement procedure.

  • Modifier/Procedure Validation

    Determines appropriateness of many variables around the relationship between procedure codes an d modifiers and if payment is allowable considering the circumstances of procedure being billed.   Also determines whether procedure inappropriate for E/M modifier or if other qualifying diagnosis would be a factor.  

    Qualifies the appropriateness and timely use of modifiers such as 25, 57, 59, 63, 92 and many more.

  • Procedure Validation
  • Timely Filing Validation
  • ICD Procedure Validation
  • Diagnosis Validation

    Valid or Invalid diagnosis codes for that particular patients' treatment with consideration to the allowable coverage.

  • Modifier Validation

    Validity of Codes and relative to dates of service

  • Place of Service Validation

    Validity of Codes and relative to dates of service

  • Type of Bill Validation
  • Date Field Validation
  • National Provider Identifier Validation
  • ZIP Code Validation
  • Form Field Content Validation
  • National Drug Code Validation
  • End Stage Renal Disease (ESRD) Validation
  • Revenue Code Validation
  • Diagnostic Related Group (DRG) Validation
  • Major Diagnostic Category Validation
  • Ambulatory Payment Classification Validation
  • Ambulatory Payment Classification Grouper
  • Medicare Fee Calculation and Adjustment
  • Medicare ASC Rate Calculation and Adjustment
  • Relative Value Units
  • Taxonomy Code Validation
  • Dental Code Validation
  • Usage Validation
  • Diagnosis not typically reported for males
  • Place Of Service/Procedure Validation
  • Patient History Validation
  • Medically Unlikely Edit Testing
  • Physician Quality Reporting System (PQRS) Testing

    PQRI denominator criteria met

  • Custom Tests – (Return Fields Vary)

    Data missing, could not perform custom test
    Custom procedure requirement not met
    Custom modifier requirement not met
    Custom medical necessity edit triggered
    Custom supervising provider requirement not met
    Procedure is always bundled, and will not be separately reimbursed
    Insured ID does not match format specifications
    Insured Group or Policy Number does not match format specifications
    Custom charges requirement not met
    Physician not listed on schedule
    PQRI denominator criteria met
    Custom occurrence span requirement not met
    Custom taxonomy code requirement not met

  • Outpatient Prospective Payment System Edits
  • Usage Validation
  • Medicare Code Editor Edits


Prevalent, Inc. a subsidiary of Axcension, Inc.

For more information or to see a demo of our product please contact us today.

23537 Kingsland Blvd Suite 124, Katy, TX 77494    l    (832) 413-5990  contactus (@)




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