April 18, 2019
Cross-functional claims editing is the comparison of different claim types. In the Claims Editor tool, we compare processed professional claims against processed facility claims status. The goal is to decrease the amount of double-submission payments of the professional and technical components of these services and ultimately lower costs for our members.
The CMS Physician Fee Schedule can be used to identify which codes have a professional/technical split. The payment policies on professional and technical component billing can be reviewed using the following links:
Here’s an example of cross-functional claims editing:
Comparison of professional laboratory and radiology services and facility claims billing laboratory or radiology services
Lab and radiology service billed on a professional claim should be submitted with modifier 26 to indicate the professional component of a service if it’s the only service provided. Without the modifier, it indicates the professional service was the global submission of the service, both the professional and technical portions of the lab or radiology procedure. That professional claim is compared against a facility claim to determine if the same services were rendered by the facility. If there’s a duplication of services billed, the professional claim will be denied reimbursement as a duplicate service.
It’s critical that any service that has a “professional/technical/global” billing capability be submitted with the correct modifiers. This helps distinguish the components rendered by the submitting provider, unless the global service was truly rendered by the professional or facility.