For Specialized Providers

Claims Quality

Many provider types still struggle producing “clean claims.” The goal of course is to produce 100% clean claims. So what is a clean claim? Correct completion of a claim is crucial to filing a clean claim. A clean claim has no deficiencies that delay payment.

From the payer’s perspective, facility and professional claims are considered to be “clean” if they meet the following general requirements:

  • All required information and data elements has been received,
  • The claim has been properly, accurately and completely coded,
  • Only medically necessary services provided are provided,
  • Payment liability (i.e. subscriber, patient demographics) can be established, and
  • Most importantly, a claim that has not been denied.

Understanding complex billing rules, medical necessity criteria, coding rules and numerous payer regulations is the key to meeting the goal of 100% clean claims. HSMN staff has expert knowledge of payment rules, particularity Medicare and Medicaid. Our approach to performing a claims assessment starts with scheduling – determining why the patient was presenting for care. We follow the patient encounter/stay through to looking at the Remittance Advice to ensure that the payor has appropriately adjudicated the claim.

HSMN has been performing specialized provider management assessments and revenue cycle assessments for over 20 years. As part of our medical documentation, coding and billing assessments, we follow the patient encounter from appointment scheduling all the way though to account reconciliation.

Procedure Coding

Procedural coding is complex; more so in some specialties such as services related to end Stage Renal disease, then in others. For specialized providers, procedural coding can definitely be challenging due to a shortage of individuals who have expert knowledge in reporting services for specialized provider types; each reimbursement methodology being unique to the provider type.

Therefore, the provider risks losing revenue or risks non-compliance due to inaccurate, incomplete coding.


After a warning from the AMA that the new diagnosis code set; ICD-10, would pose too great a burden for providers, CMS announced that the Obama administration would look into delaying a transition to ICD-10. Providers should consider this potential delay as an opportunity to develop a personalized roadmap to ICD-10 transition.

Fortunately, most specialized providers will only be impacted by ICD-9-CM diagnosis code changes but going from a classification system that has 14,000 diagnosis codes to a system that has approximately 68,000 diagnosis codes will still require significant preparation.

ICD-9 Coding Specificity & Medical Necessity

Many providers types place little importance on diagnosis coding; however, carelessness in diagnosis coding can lead to denied claims. Diagnoses are relevant to reimbursement in two respects:

  • Specificity
    • In the context of ICD-9-CM coding, the “highest degree of specificity” refers to assigning the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis.
  • Medical Necessity
    • Defined as accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, illness or injury and consistent with standards of care. Payor coverage determinations determine medical necessity criteria for specified diagnostics and services.

Coding Specialties

  • Allergy & Immunology
  • Anesthesiology
  • Cardiology
  • Colon and Rectal Surgery
  • Dermatology
  • Emergency Medicine
  • Family Medicine
  • Gastroenterology
  • General Surgery
  • Hematology/Oncology
  • Infectious Disease
  • Internal Medicine
  • Medical Genetics
  • Nephrology
  • Neurology
  • Neurosurgery
  • Nuclear Medicine
  • Obstetrics and Gynecology
  • Ophthalmology
  • Orthopaedic Surgery
  • Otolaryngology
  • Pathology-Anatomic/Pathology-Clinical
  • Pediatrics
  • Physical Medicine and Rehabilitation
  • Plastic Surgery
  • Preventive Medicine
  • Psychiatry
  • Pulmonary Medicine
  • Radiation Oncology
  • Radiology/Interventional Radiology
  • Rheumatology
  • Thoracic and Cardiac Surgery
  • Transplant
  • Urology
  • Vascular Surgery

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