• A modifier added to an edit with indicator 0, which can’t be bypassed.On remittances, look for bundling codes such as

Why it matters in orthopedics

Every claim that stops for manual work costs staff time and delays payment. Orthopedic claims have plenty of places to stop: NCCI procedure-to-procedure edits on same-session procedures, unit limits, modifiers tied to global surgical periods, DME documentation, authorizations for imaging and surgery, and workers’ comp claim numbers. In Experian Health’s 2025 State of Claims survey, 68% of providers said submitting clean claims was harder than a year earlier.

How to calculate it

HFMA’s MAP Key CL-1 is the standard definition:

Clean claim rate = claims that pass edits requiring no manual intervention ÷ claims accepted into the claims processing tool for billing

HFMA counts each claim the first time it is scrubbed, includes primary, secondary and tertiary claims, and leaves out claims sent directly to a payer without passing through your edits. For example, 10,800 clean claims out of 12,000 scrubbed is a 90% clean claim rate.

Two related metrics are often confused with it:

• Acceptance rate: the share of submitted claims that pass clearinghouse and payer front-end checks.

• First-pass resolution rate: the share of claims paid or otherwise resolved on the first adjudication, with no correction, resubmission or appeal. It is not a MAP Key, so write down your definition.

Medicare uses “clean claim” differently, for prompt-payment purposes. Its claims processing manual describes a clean claim as one the contractor can process without investigating outside its Medicare operation. Contractors must pay or deny clean claims within 30 days and cannot pay electronic claims until a 13-day waiting period has passed.

Orthopedic benchmark

We found no published orthopedic benchmark. In a November 2024 MGMA article on managing revenue cycle vendors, a consultant noted that a 90% clean claims rate is generally considered industry best practice. Vendor guests on an April 2025 MGMA podcast put the ideal around 95%. Treat 90% to 95% or higher as a rule of thumb and trend your own rate monthly. Our orthopedic RCM benchmarks guide compares it with the other core metrics.

What moves it

• Registration and eligibility errors, including a wrong payer or member ID.

• Missing or mismatched authorizations.

• Coding and modifier edits, such as NCCI pairs, unit limits and global-period modifiers.

• Missing documentation or required claim data, such as a workers’ comp claim number.

• Scrubber configuration: adding edits can lower the clean claim rate while preventing denials.

How to improve it

• Rank edits by volume each month and fix the top causes where they start, such as registration or documentation.

• Verify eligibility and authorization before the visit or surgery date.

• Keep payer-specific rules and NCCI edits current in your scrubber.

• Give surgeons and coders feedback on edits driven by documentation.

• Read it alongside your denial rate. If clean claims rise and denials rise too, your edits are probably missing payer rules.