News You Can Use: Get Ready for Another Set of Coding Edits -- Thanks to CMS’ New MUEs.

As of January 2007, you have a new set of coding “edits” from CMS to contend with. These “Medically Unlikely Edits” (MUE) are separate from the already-established National Correct Coding Initiative (NCCI) edits. But if the edits function as intended, youfind them more a help than a hindrance.

Prevent Overpayment From Gross Mistakes

The new MUEs are a refined version of the “Medically Unbelievable Edits” that CMS initially proposed--and then, due to provider concerns, withdrew--in 2005.

The goal of the new edits is to prevent overpayments caused by gross billing errors, usually due to clerical or billing system mistakes, said Niles R. Rosen, MD, medical director for Correct Coding Solutions LLC, which has worked hand-in-hand with CMS to develop the current edits, during a presentation at the AMA CPT and RBRVS 2007 Annual Symposium.

Rosen cited an example of a single CT scan that was billed (and inappropriately paid) as 10,001 units of service, as well as a shoulder arthroscopy billed as 141 units of service. “The number 141 was actually the minutes of anesthesia,” he said.

“The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period,” Rosen said. The maximum units of service for a given CPT code have not been assigned arbitrarily but by using common-sense criteria.
Edits Operate per Line, Not per Claim

If you do run afoul of the edits, you won’t face denial for your entire claim, but only the single line item that violates the MUE guidelines, Rosen said. You will be able to appeal MUE edit rejections in the rare event you think your claim was appropriately billed and meets the requirements of medical necessity.

Like the NCCI, the MUE will be updated quarterly and be subject to continuing refinement. “CMS and Correct Coding Solutions welcome suggestions and comments from providers,” Rosen said.



- Published on 2007-03-01