CMS Expands Medically Unlikely Edits for the New Year

Contact your payer before an "unusual" surgery, or face denial
The controversial medically unlikely edits (MUEs) that CMS instituted in 2007 are set to expand into new areas starting in January -- and your claims could wind up on the chopping block as a result.
The lowdown: Until now, the MUEs have focused on anatomically unlikely scenarios. For example, if you try to bill for a hysterectomy on a male patient or amputation of three arms, these edits will kick in and prevent it. But starting in January, MUEs will additionally focus on "clinical judgment" issues.
As before, the MUEs will limit the number of units of a particular code your doctor can bill. Now, in addition to looking for hysterectomies on male patients and other anatomical impossibilities, the edits will limit "unlikely" situations, such as if a surgeon tries to bill for 15 skin biopsies in one session.
As another example, if a surgeon tries to report amputating more than six digits in one session, the MUE edits may kick in, says William Rogers, MD, head of the Physician Regulatory Issues Team at the CMS. Removing six fingers in one session is "not impossible, but unlikely," he explains.
Coming up with edits based on likely clinical scenarios is trickier than crafting ones based on anatomic impossibility, Rogers concedes. But CMS has been using a "very inclusive and consensus-driven" policy to craft the new edits, so "I’m not too anxious about it," he says.
Economy drives edit decisions: Medicare is processing a billion physician claims a year on a budget of less than $1 per claim. "You can’t afford to have every claim individually reviewed," Rogers says. So making the claims pass through a computerized screen is the only way to prevent "unscrupulous people" from billing for whatever they want.

Modifiers Won’t Defeat MUEs

At present, you can’t use any modifiers to override the MUEs based on anatomic impossibility. Some physician groups have suggested that CMS allow modifiers for these new "clinical judgment" MUEs, but the agency has demurred. For now, if you must file a claim that is true but seems unlikely, you can contact your carrier ahead of time to avoid an improper denial, CMS officials have suggested.
You’re flying blind: Physicians have asked CMS to make the list of MUEs public. CMS has declined, answering that some providers could misuse that list to bill for the maximum possible number of units of a particular code, avoiding the edits but still billing fraudulently.
Tip: Scrutinize your Explanations of Benefits (EOBs) to look for remark code N362. This remark code represents units of [...]

- Published on 2007-11-27