When a claim fails an NCCI edit, which position in the revenue cycle would most likely take the lead on resolving the edit?

When a claim fails a National Correct Coding Initiative (NCCI) edit, the Patient Financial Services (PFS) personnel are typically in the best position to address and resolve these edits. This is because PFS personnel are specifically trained in the financial aspects of claims processing, including the nuances of coding and billing rules. They understand how to interpret the edits and have the responsibility of ensuring that claims meet compliance requirements before they are submitted for payment.

PFS personnel play a crucial role in managing the flow of the revenue cycle, acting as the bridge between clinical documentation and billing processes. They possess the necessary knowledge of coding guidelines and are equipped to make adjustments or gather further information needed to successfully override or appeal the edits. This expertise allows them to effectively communicate with other departments, such as clinical and coding staff, to collaboratively resolve any issues leading to the claim denial.

In contrast, while billing department auditors and compliance officers play important roles in reviewing and ensuring the accuracy of claims, their focus is typically more on auditing for compliance and accuracy post-processing rather than actively resolving coding edits. Clinical staff members are more involved in providing the documentation and clinical information necessary for coding rather than directly handling edits related to billing practices. Hence, the PFS team is the primary group responsible