Medicare Compliance & Reimbursement

CMS has reversed a decision, and for once, that's a good thing.

Despite the agency's insistence that it would not publish its list of medically-unlikely edits (MUEs), CMS changed course, and published the listing on Oct. 1.

The MUE program aims to help CMS "dramatically reduce costly payment errors," said CMS Acting Administrator Kerry Weems in an Oct. 1 statement. However, the news release acknowledges that "CMS has not yet determined if there have been any savings in the MUE program since it was implemented" in January of 2007.

The MUE list differs from standard CCI edits in that it does not include code pairs. Instead, it lists specific CPT or HCPCS codes, followed by the number of units that CMS will pay. For example, the MUEs allow you to report only one unit of 40800 (Drainage of abscess, cyst, mematoma, vestibule of mouth; simple). You can, however, report two units of code 40818 (Excision of mucosa of vestibule of mouth as donor graft).

Important: The list of MUEs on the CMS Web site is not entirely complete. "The published MUE will consist of most of the codes with MUE values of 1-3," the Oct. 1 notice indicates. "CMS will not publish all MUE values that are 4 or higher because of CMS concerns about fraud and abuse," it states.

What to expect: The MUEs probably won't offer too many surprises, with the surgical codes featuring the most MUEs and the anesthesia code series with the fewest.

Following is a sampling of codes that allow one, two, or three units billed to Medicare:

Indicator of 1: You can report just one unit of the following codes before the MUEs kick in:

• 11100 -- Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

• 42809 -- Removal of foreign body from pharynx

• 37600 -- Ligation; external carotid artery

• 99201-99211 -- Office or other outpatient visit...

"It's a little bit surprising that the other established patient E/M codes from 99212-99215 aren't on the MUE list," says Alexis Riegel with Anderson Family Practice. "But then again, CMS says it didn't list all of the MUEs in the file."

Indicator of 2: You can report two units of the following codes before the MUEs kick in:

• 29877 -- Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

• 43760 -- Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance

• 62142 -- Removal of bone flap or prosthetic plate of skull

Indicator of 3: You can report three units of the following codes before the MUEs kick in:

• 77781 -- Remote afterloading high intensity brachytherapy; 1-4 source positions or catheters

• 86382 -- Neutralization test, viral

• L3933 -- Finger orthosis, without joints, may include HCPCS soft interface, custom fabricated, includes fitting and adjustment.

To read the complete list of MUEs or to find out more about the MUE program, go online to the CMS Web site at http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage.