Claims Scrubber

The Claims Scrubber runs a set of rules on every insurance claim before it is submitted. Required-information checks are built in and always run. On top of those, add custom rules for the problems payers reject claims for, such as a telehealth visit that is missing modifier 95 or a procedure billed without a prior authorization. A rule can block submission until the claim is fixed, or just warn the biller.

How the scrubber runs

The scrubber runs at two points:

When a biller clicks "Mark Ready to Submit" on a claim. The claim only moves to "Ready to Submit" if it passes.
When a biller clicks "Submit Claims" on the Claims page. Every selected claim is checked again before anything is sent to the clearinghouse.

Each rule that fires produces a finding, shown as the rule's name followed by its flag message. What happens next depends on the rule's severity:

Blocks Submission: The claim is held back. On the claim, a red panel reads "This claim isn't ready to submit yet" and lists the findings. On the Claims page, the claim appears under "Held back" and its status changes to "Missing Information".
Warning Only: The biller sees the finding but can proceed. On the claim, an amber panel lists the warnings with a "Submit Anyway" button. On the Claims page, the claim appears under "Needs your confirmation" with a "Submit anyway" button.

The built-in required-information checks always block. They are: patient first name, last name, date of birth, and address; billing provider; service facility; primary insurance policy; at least one diagnosis; and at least one billing item.

Follow the instructions here for the full submission flow.

Steps

Step 1: Create a rule (EMR)

Go to the EMR (e.g. emr.avonhealth.com)
Click on the hamburger menu on the top left corner > Settings > Modules > Claims Scrubber
Click "Create Rule" in the top right corner
Enter a name that describes the problem (e.g. "Telehealth visits need modifier 95") and click "Create"

The rule opens in the editor. Everything entered is autosaved.

Step 2: Set the rule details (EMR)

Under "Rule Details":

Name and Description: What the rule is for. The description is shown on the rules list.
When the check fails: Choose "Blocks Submission" or "Warning Only". Use "Blocks Submission" for anything the payer will definitely reject, and "Warning Only" for judgment calls a biller should review.
What it offers: Choose "Suggest Edit" if the fix follows from the conditions (for example, add a missing modifier), or "Flag Only" if a person needs to decide what to do.
In force from: Optional start and end dates. The rule only runs on claims whose date of service falls inside the window, so a payer policy that took effect in January does not flag December's visits. Leave both empty and the rule runs whenever it is turned on.

Step 3: Write the conditions (EMR)

Under "Rule Content", the heading reads "Flag the claim when all of this is true". Describe the bad state, not the requirement. A telehealth visit billed without its telehealth modifier is written as:

Procedure is 99213, and
Place of service is 10: Telehealth Provided in Patient’s Home, and
Modifiers is not one of 95

Read back: flag an established-patient office visit that was delivered to the patient's home by telehealth but does not carry modifier 95.

Each condition is a field, an operator, and a value. Values are picked from lists or searched, not typed, so a rule cannot reference a code that does not exist.

Click "+ Add condition" to start, then "+ And another condition" to add each further condition to the same group. Every condition in a group has to hold for the rule to fire.

To catch the same problem in two different ways, click "+ Or a different group". Groups are joined by "OR", so the rule fires when any one group holds. Use this when a payer's edit covers two procedure codes that need different modifiers, rather than writing two rules.

The fields available to check:

Payer: The payer on the patient's primary insurance policy. Pick from the payer list.
Procedure: The CPT or HCPCS code on a billing item. Search by code.
Modifiers: The modifiers on a billing item. Pick from the modifier list.
Diagnosis on the line (ICD-10 code): The diagnoses attached to a billing item. Search by ICD-10 code.
Diagnosis on the claim (ICD-10 code): Every diagnosis on the claim.
Primary diagnosis (ICD-10 code), Secondary diagnosis (ICD-10 code), and Tertiary diagnosis (ICD-10 code): The claim's diagnoses by position.
Prior authorization number: Whether the claim has one.
Service facility and Billing provider: Pick from the organization's service facilities and billing providers, or check whether the claim carries one at all.
Place of service: The place-of-service code on a billing item. Pick from the list.
Referral number: Whether the claim has one.
Sex: The patient's sex.
Patient age: The patient's age in years.
Patient address state: The state on the patient's address.
Units: The quantity on a billing item.
Procedures on the same date of service: Every CPT code billed on the same day as the line being checked. Use this for add-on codes and code pairs that cannot be billed together.
Procedures on the claim: Every CPT code on the claim.

The operators are "is", "is not", "is one of", "is not one of", "exists", "is missing", "is more than", "is at least", "is less than", and "is at most". Each field only offers the operators that make sense for it: a payer is never asked whether it exists, a prior authorization number and a referral number are only ever asked whether they exist or are missing, and only the numeric fields, Units and Patient age, offer the comparisons. Changing the field on a condition resets its operator and value to ones the new field offers.

For list fields such as Modifiers and the diagnosis fields, "is one of" matches when any entry in the list matches, and "is not one of" matches when none do. So "Modifiers is not one of 95" means the line does not carry 95, which is how a biller reads it.

A rule's scope is not a setting. A rule that mentions a line field (Procedure, Modifiers, Diagnosis on the line, Place of service, Units, or Procedures on the same date of service) is checked once per billing item. A rule that only mentions claim fields is checked once per claim.

Step 4: Write the flag message (EMR)

Under "Flag message", enter what the biller should read when the rule fires (e.g. "Telehealth visit is missing modifier 95"). Leave it empty and the conditions themselves are shown instead.

Step 5: Turn the rule on (EMR)

New rules start as drafts and do not run — the header reads "Off — this rule does not run yet". When the rule is ready, click "Turn on" at the top of the page. The header changes to "Active — runs on every claim before submission". A rule cannot be turned on until every condition has a field, an operator, and a value; if a condition is incomplete, the page reads "We couldn't activate this rule. Check the conditions and try again."

To stop a rule without deleting it, click "Turn off".

Step 6: Manage rules (EMR)

The Claims Scrubber page groups rules under three tabs, and opens on "Active":

Draft: Created but not yet turned on
Active: Running on every claim before submission
Archived: No longer running. The findings an archived rule produced are kept.

Each rule shows its severity. Click the archive icon on a rule to archive it, or the restore icon on an archived rule to bring it back as a draft.

Rules marked "Standard" are maintained by Avon. How a standard rule behaves and when it is in force can be changed, but not its conditions. To check for a variation of a standard rule, archive it and add a custom rule instead.

Example rules

Each example is written the way it appears in the editor.

Diagnosis to procedure: Procedure is 99213, and Diagnosis on the line is not one of I10. Flags a procedure billed without a diagnosis that supports it.
Modifiers required: Procedure is 99213, and Place of service is 10: Telehealth Provided in Patient’s Home, and Modifiers is not one of 95. Flags a telehealth visit without the telehealth modifier.
Modifier compatibility: Procedure is 99213, and Modifiers is one of 59. Flags a modifier that is not valid with the procedure.
Procedure combinations: Procedure is 99213, and Procedures on the same date of service is one of 20610, and Modifiers is not one of 59. Flags two procedures billed on the same day without the modifier that allows it.
Units of service: Procedure is 99213, and Units is more than 2. Flags more units than the payer allows.
Add-on codes: Procedure is 99354, and Procedures on the same date of service is not one of 99213. Flags an add-on code billed without its primary code.
Authorization: Procedure is one of 97110, and Prior authorization number is missing. Flags a procedure that needs a prior authorization the claim does not carry.

Tips for writing rules

One problem per rule. The rule's name and flag message tell the biller exactly what to fix.
Describe the bad state. Conditions say when to flag, so write the combination that should not go out, not the requirement.
Use "Warning Only" first. Turn a new rule on as a warning, watch what it catches for a week, then switch it to "Blocks Submission" once it is trusted.
Scope by payer. Most edits are payer-specific. Add a "Payer is" condition so the rule does not flag other payers' claims.
Use the in-force dates for policy changes. When a payer changes a requirement, set the start date on the new rule and the end date on the old one instead of editing the old rule.