Oncology & Hematology Coding Alert

Starting Jan. 1, these CMS edits hunt down unit mistakes
 
All-new -Medically Unlikely Edits- (MUEs) aim to limit maximum units of service for CPT codes by using common-sense criteria. 

Goal: The edits should prevent overpayments caused by gross billing errors, usually as the result of clerical or billing system mistakes, said Niles R. Rosen, MD, medical director for Correct Coding Solutions LLC, which has worked hand-in-hand with CMS to develop the current edits, during a presentation at the AMA CPT and RBRVS 2007 Annual Symposium in Chicago.

Rosen cites an example of a single CT scan that was billed (and inappropriately paid) as 10,001 units of service.

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

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. You will be able to appeal MUE edit rejections in the rare event you think  your claim was appropriately billed and meets the requirements of medical necessity.

MUEs are a refined version of the -Medically Unbelievable Edits- that CMS initially proposed -- and then, due to provider concerns, withdrew -- in 2005.

Note: These edits won't be published, similar to the frequency edits you-ve dealt with from your Medicare contractor systems.