Oncology & Hematology Coding Alert

Put the appeals process to work when medical necessity supports your claim.

Medically unlikely edits (MUEs) aren’t on most coders’ lists of favorite things, and the all new date-of-service (DOS) MUEs probably won’t help. But as of April 1, 2013, CMS has put these DOS frequency edits into play.

What this means: CMS will continue to use the type of MUEs you’re familiar with, checking the number of units for a single line item against the MUE frequency edit for the code. The MUE value represents the maximum units expected to be reported for most patients.

But now CMS is also using DOS MUEs for certain codes. For DOS MUEs, all units reported for a code on a single DOS will be added together and checked against the MUE value. Unfortunately, CMS doesn’t plan to publish which codes have DOS MUEs.

Why the change? The Government Accountability Office (GAO) recommended the implementation of DOS MUEs, according to a letter to the AMA from Niles R. Rosen, MD, medical director of the National Correct Coding Initiative and the MUE program. Studies by the GAO and Office of Inspector General (OIG) discovered providers getting extra reimbursement by using multiple line items to avoid MUEs.

Don’t Accept Every MUE Denial

If you disagree with a denial based on a DOS MUE, you will be able to appeal just as you can appeal line-item denials, according to CMS FAQ 8119 (search for it at https://questions.cms.gov/faq.php).

“If the practice does not agree with the MUE, and can support their coding and billing, I would recommend appealing,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “They will probably lose at the first level, Redetermination, but if they have a good case with good clinical documentation, there is a good chance that the practice might win at the Reconsideration or Administrative Law Judge level of appeal.”

Here are three steps that have been used to deal with line-item MUE denials:

Step 1: Determine the reason for the denial. First, figure out if you made a coding or billing error. If you find a coding error — such as the wrong number of units entered in the units box — submit a corrected claim. If you don’t find a coding or billing error, move on to the next step.

Step 2: Decide if you have a legitimate reason to appeal. Review the case to see whether there was medical necessity for the services over the MUE value. If so, you should appeal to the contractor.

Step 3: Appeal the claim. File an initial appeal with your contractor and follow the standard five-level Medicare appeals process. “If appealing the claim due to a clinical reason, you may wish to employ clinical expertise when putting together your appeal letter,” suggests Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, president of ComplyCode in Binghamton, N.Y.

Tip: “Just because you win an appeal, you will not change the MUE edit,” Cobuzzi warns. “To get it changed, you need to go to your CAC (Carrier Advisory Committee) and your payer’s medical director and try to get the MUE edit changed. Winning some appeals with a terrific clinical case and documentation provides a good foundation to go to the CAC and the medical director to try to get the MUE edits changed.”