General Surgery Coding Alert

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 situations such as when 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 MUEs may kick in, says William Rogers, MD, head of the Physician Regulatory Issues Team at CMS. Removing six fingers in one session is "not impossible, but unlikely to be seen in a normal practice," he says.

Coming up with edits based on likely clinical scenarios is trickier than crafting ones based on anatomic impossibility, Rogers says. 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.

Beginning Jan. 1, HCPCS will offer a new modifier, GD (Units of service exceed medically unlikely edit value and represent reasonable and necessary services), to avoid MUE-related denials. CMS has not yet announced whether this modifier will apply to both CPT and HCPCS codes. But assuming it does apply to both, modifier GD could come in handy for many practices.

"Suppose the surgeon bills for two appendectomies because the patient has a native one and one attached to his transplanted organ," says Suzan Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh Physicians Department of Surgery. "This would be a medically unlikely scenario, but one that happened nonetheless."

You-re flying blind: A serious problem, however, is that providers do not know which procedures are subject to MUEs. Physicians have asked CMS to make the list of MUEs public, but the agency 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 Explanation of Benefits (EOBs) to look for remark code N362. This remark code represents units of service "exceeding an acceptable maximum" and may mean your claim has fallen afoul of the MUEs. Remember, you can't bill the patient for services denied due to MUEs.