Claim Scrubbing Best Practices

1. Patient Eligibility & Coverage

• □ Verify coverage is active as of the date of service
• □ Check the patient's deductible status — has it been met this year?
• □ Confirm the payer — don't assume secondary insurance information is current
• □ Look for exclusions — some services are excluded for specific diagnoses
• □ Check benefit limits — annual maximums, frequency limits (PT visits, etc.)

Denial code this prevents: PR-1 (not on plan), CO-119 (benefit max reached)

2. Diagnosis & Procedure Code Match

• □ Does the primary diagnosis support the CPT code? (e.g., knee pain code should match knee procedure, not shoulder)
• □ Is there a diagnosis exclusion? Some payers don't cover certain procedures for certain diagnoses
• □ Check payer policies for specific diagnosis-procedure combinations known to be problematic

Denial code this prevents: CO-96 (non-covered service), CO-233 (criteria not met)

3. CPT & ICD-10 Code Accuracy

• □ Check CPT code accuracy — is the code actually describing the service provided?
• □ Verify ICD-10 code specificity — use the most specific code available (5th/6th character specificity)
• □ Check for typos — one digit off ruins the claim
• □ Verify code is valid for 2025 — codes change every January

Denial code this prevents: Multiple, depending on the error

4. Modifier Review

• □ Bilateral procedures — is -50 modifier needed? If both knees were treated, payers need to know
• □ Multiple surgeries — do you need -51? When multiple procedures happen in one session, proper modifiers are essential
• □ Component codes — which -LT/-RT modifiers are needed? Anatomical side matters
• □ Check bundling rules — some codes bundle together and shouldn't be billed separately

Missing modifiers are among the most common coding errors and trigger denials automatically.

5. Documentation Completeness

• □ Are clinical notes present? Billing without docs is automatic denial territory
• □ Do notes show medical necessity? See our guide
• □ Are exam findings documented? "Normal" exams don't justify treatment
• □ Is the plan documented? Treatment goals, expected duration, follow-up plan?

Denial code this prevents: CO-16 (missing information), CO-233 (criteria not met)

6. Prior Authorization Verification

• □ Was prior auth required? Check the payer's website or patient benefit statement
• □ Do you have written approval? Verbal approvals aren't enough
• □ Is the approval still valid? Check the dates. Some approvals expire
• □ Do the approved codes match? If PA was approved for different CPT codes, don't change them

Many practices bill without PA when it was required. Automatic denial.

7. Billing & Submission Details

• □ Correct payer info? Wrong payer address = lost claim
• □ Your NPI and credentials correct? Mismatched info triggers rejections
• □ Charges reasonable? Outlier charges get audited and often reduced
• □ Is this a duplicate? Check your system for prior submissions to avoid CO-72 denials

Clearinghouses

Most clearinghouses perform basic scrubbing: syntax checking, code validity, provider verification. This catches 30-40% of errors.

EHR Built-In Scrubbing

Many EHRs have integrated scrubbing rules. Configure them with your payer-specific rules to catch common problems before export.

Dedicated Scrubbing Software

Tools like 3M, Optum, and others offer advanced scrubbing with payer-specific rules, bundling logic, and medical necessity analysis.

AI-Powered Scrubbing

RediClaim's pre-submission analyzer uses AI to check claims against clinical documentation, catch missing modifiers, and predict denial risk before you submit.