Medicare Compliance & Reimbursement

The 'unlikely' will definitely happen -- will you be ready?

Brace yourself: Beginning in January 2007, you'll have to contend with a new set of coding "edits" -- separate from the already-established Correct Coding Initiative (CCI) edits -- from Medicare. If the edits function as intended, however, you should find them more a help than a hindrance to your practice.

The new "Medically Unlikely Edits" (MUEs) are an undated and refined version of the "Medically Unbelievable Edits" that the Centers for Medicare & Medicaid Services (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 as the result of clerical or billing systems' mistakes, explained Niles Rosen, medical director for Correct Coding Solutions -- which has worked with CMS to develop the current edits -- during a presentation at the American Medical Association's (AMA) CPT and RBRVS 2007 Annual Symposium in Chicago. "The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period," Rosen explained.

Rosen cites 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 explained. The first batch of MUEs will focus on anatomically impossible claims, with other edits that CMS will phase in over time.

Example: The MUEs would limit the number of simple repair codes (12001-12021) per anatomic location that you may bill per claim. Therefore, for instance, you would never code for simple repairs of the trunk using both 12001 (...2.5 cm or less) and 12004 (...7.6 to 12.5 cm) for the same patient during the same session. Instead, you would add the lengths of the various repairs and report a single unit of service, such as 12005 (...12.6 to 20.0 cm).

Also, the edits will limit the claims for 99304 (Initial nursing facility care, per day...) to a single unit per calendar day. This makes sense, as 99304 is a "per day" code.

Other forthcoming MUEs will limit codes according to CMS policy. For example, ophthalmology biometry code 76516 has a bilateral indicator of "2," so you should never bill two or more units of this code, Rosen noted. Other edits will focus on the nature of the equipment for testing, the study or procedure, or pathology specimen. So, for example, you can't bill more than one unit of a 24-hour study per day. 

One advantage of the MUEs is that 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 explained.

In addition, you will be able to appeal MUE edit rejections if you feel that your claim was appropriately billed and meets the requirements of medical necessity.

"However," Rosen stressed, "we have designed the edits such that there should be an absolute minimum of inappropriately rejected claims. The criteria we use are meant to catch egregious errors, not to prevent legitimate services from being paid."

Like the CCI, 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.

Don't wait for a denial: If your physician really has a patient with an anatomic abnormality, you should contact your carrier in advance instead of waiting to appeal a denial based on the MUEs, says a CMS spokesperson. For example, if your patient has three arms and you amputate all three of them, you should let your carrier know and ask what documentation you should submit to support this claim.

No publication: The MUEs won't be published or posted on the CMS Web site, the CMS source says.