Medicare Compliance & Reimbursement

MUEs sail past anatomy into the realm of clinical decision making

Warning: The controversial medically unlikely edits (MUEs) are taking a big step into the unknown starting in January ...quot; and your claims could wind up on the chopping block as a result.

Big change: 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, Phase V of the MUEs will focus on "clinical judgment" instead.

The MUEs will limit the number of units of a particular code your doctor can bill. Now, in addition to snooping out two brains, the edits will govern situations where your doctor tries to bill for 15 skin biopsies in one session.

Or, if your doctor tries to bill for amputating more than six digits in one session, the edits may kick in, says William Rogers, a physician and head of the Physician Regulatory Issues Team at the Centers for Medicare & Medicaid Services. Removing six fingers in one session is "not impossible, but unlikely to be seen in a normal practice," 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."

Currently, you can never use modifiers to override the MUEs that are based on anatomic impossibility. Some physician groups have suggested allowing modifiers for these new "clinical judgment" MUEs. For now, though, if you have a case that is true but seems unlikely, you can contact your carrier ahead of time, CMS officials
have suggested.

Eventually, CMS will have MUEs for most CPT and HCPCS codes, according to specialty societies.

Physicians asked CMS to make the list of MUEs public. But CMS responded 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.

So it's important to scrutinize your Explanation of Benefits (EOBs) to look for remark code N362, says the American Association of Oral and Maxillofacial Surgeons. 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.