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Medicare Compliance & Reimbursement

CODING:

Believe It Or Not, You May Be Able To Bill For Unlikely Services

Published on Mon May 15, 2006

Watch out for MUE proposed in August.

Good news: You may not have another smothering layer of edits coming down on your claims in January after all.

The Centers for Medicare & Medicaid Services (CMS) had planned to impose medically unbelievable edits (MUEs) on every single code starting in January 2007. These edits would have focused on cases where you billed for too many units of a particular code, or performed a procedure twice when it should only happen once.

Many physicians complained that the MUEs would have made it impossible to bill for situations where a patient needed an unusual amount of services. Also, the edits would have been imposed on some codes it makes no sense to limit by units.

Limited roll-out: At the May 22 meeting of the Practicing Physicians Advisory Council, CMS officials agreed to phase in MUEs more cautiously. The first batch of edits, which take effect in January, will only focus on "anatomic abnormalities and obvious typographical errors," according to the College of American Pathologists. This first batch of edits will be released for comment in August.

"It's going to focus just on the really, really medically unbelievable and not the medically unlikely on the first round," says William Rogers, a physician who chairs the Physician Regulatory Issues Team at CMS.

An example of a genuinely unbelievable service would be a hysterectomy on a male, notes Joe Johnson, a Paxton, FL chiropractor and PPAC member. When CMS does expand the edits to include more scenarios, they may be named "medically unlikely" instead of "medically unbelievable," to acknowledge that unusual circumstances do happen.

Modifier may be allowed: And CMS officials left open the possibility that you may be able to use a modifier to override the MUEs if something really bizarre does happen. The officials didn't say for sure, but allowing a modifier should prevent the need for paper resubmission of claims, notes Rogers.

Clearer EOBs: When your claim is denied due to MUEs, the explanation of benefits (EOB) will explain clearly why, according to Johnson. The EOBs will be "more informative and less confusing" than originally planned, CMS promised according to Johnson.

Sometimes things that appear unbelievable do occur, note physicians. For example, a female-to-male transsexual could be listed as male but have a hysterectomy, notes one physician.

Also, a patient could have her spleen removed, and then have a second spleen-removal surgery, according to Robert Urata, a family practice physician in Juneau Alaska who serves on the PPAC. Some unusual people have a second spleen, known as an accessory spleen. "The human body is not uniform," Urata concludes. That's why it's important to be able to use a modifier to override the MUEs.

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