Neurology & Pain Management Coding Alert

CMS delivers new category of long-promised edits

One change to your coding in 2007 is the addition of a new set of coding -edits- -- separate from the already-established National Correct Coding Initiative (NCCI) edits -- from CMS. If the edits function as intended, however, you should discover that they help more than  hinder your practice.

Edits Prevent Gross Mistakes

The new -medically unlikely edits- (MUEs) are an undated and refined version of the -medically unbelievable edits- that CMS initially proposed -- and then withdrew due to provider concerns -- 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, said Niles R. Rosen, MD, medical director for Correct Coding Solutions LLC, during a presentation at the AMA CPT and RBRVS 2007 Annual Symposium in Chicago. Correct Coding Solutions worked hand-in-hand with CMS to develop the current edits.

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 said.

Such inappropriate claims were not the result of outright fraud but simply big blunders on the part of the billing providers.

-The MUEs will automatically limit the number of units of service you can bill for a service in any 24-hour period,- Rosen said.

The maximum units of service for a given CPT code have not been assigned arbitrarily, but by using common-sense criteria.

Example: Limit your claims for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) to a single unit per calendar day, says Amanda Becker, senior manager of medical economics for the American Academy of Neurology. This makes sense, because 99291 is a -first hour- code; you report +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) for additional time.

Edits Operate per Line, Not per Claim

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 said.

Bonus: In addition, you will be able to appeal MUE edit rejections if you feel you appropriately billed your claim and it 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 NCCI, 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.