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Clinical Editing Policy
Manual: Reimbursement Policy
Section: Administrative
Policy Number: 001
Date of Origin: 1/22/2004
Last Updated: 5/23/2008
ODS employs clinical edits in the processing of medical claims. Our clinical edit set focuses on correct coding methodologies and accurate, appropriate adjudication of claims.
The edits have been clinically determined and validated on a code-by-code basis. The ODS clinical edit policies are based on coding conventions defined by a variety of established sources, including but not limited to:
- The American Medical Association’s (AMA) CPT manual
- The AMA CPT Assistant newsletter articles
- The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (CCI) and Associated Policies
- Coding guidelines developed by national professional specialty societies
- Specialty clinical practice guidelines
- Clinical research and practice pattern analysis
- Clinical experience of physician reviewers
- Numerous medical journals
- Medical texts
- Medical newsletters
- Coding industry newsletters
- Public health data studies
- Proprietary health data analysis
- Other general coding and claim payment references
The clinical edits are developed, maintained, and regularly updated by experienced, professional staff, including the ODS Medical Director, a large panel of board-certified physicians with specialty-matched expertise, Certified Professional Coders, and registered nurses with expertise in both medical management and clinical care.
Upon request, ODS will provide either the abbreviated or the verbatim citation of the source that defines the policy standard for a specific clinical edit.
If you disagree with the rationale (source information) for a specific clinical edit and wish to request a change in the edit settings, submit a written comment including the following minimum information:
- The HCPCS/CPT codes and descriptors in question
- The rationale information you received
- The reason you disagree with the rationale
- The proposed modification
- The justification for the proposed change
- Copies of the documentation cited in the justification
(e.g., National Specialty Society/Association coding guidelines, AMA's coding instructions in CPT itself or AMA's coding advice as referenced in the CPT Assistant,clinical medical literature, studies, standards of medical practice, national medical policy).
Your written comment and request will be reviewed, and a written response with the determination will be returned.
Please send this written documentation to:
ODS Medical Claims
Attention: Clinical Policy & Reimbursement Analyst
P.O. Box 40384
Portland, OR 97240
503-243-4498 (Fax)
Attention: Clinical Policy & Reimbursement Analyst
E-mail:
The above email address and contact information is limited to written comments regarding clinical edit system settings (not single-claim related).
For other questions or concerns, multiple resources can be found on the ODSWebsite, Medical Providers section.