Ophthalmology and Optometry Coding Alert

Experts say the edits may help, not hinder, your coding

Here it comes: Yet another set of coding regulations you'll have to pay attention towhen you're reporting your ophthalmologist's services.

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

Get to Know the MUEs

Background: The new "Medically Unlikely Edits" (MUEs) are an undated and refined version of the "Medically Unbelievable Edits" that the Centers for Medicare & Medicaid Services initially proposed -- and then, due to provider concerns, withdrew -- in 2005.

The goal: The new edits are designed to prevent overpayments caused by gross billing errors, usually as the result of clerical or billing systems' mistakes, said 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 CPT and RBRVS 2007 Annual Symposium in Chicago.

What it means to you: "The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period," Rosen said.
 
Learn Anatomical Edits First

The first batch of MUEs will focus on anatomically impossible claims, and CMS will phase in other edits 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 eyelid using both 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) and 12015 (... 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 12016 (... 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, because 99304 is a "per day" code, experts say.

Bilateral coding: 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 said.
 
In addition: 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.

Appeal MUE Denials in Some Cases

One advantage of the MUEs is that if you do run afoul of the edits, you won't face a denial for your entire claim, but only the single line item that violates the MUE guidelines, Rosen said.

In addition, you will be able to appeal MUE edit rejections if you feel that your claim meets the requirements of medical necessity. "Those individuals who are responsible for posting payments will have to be on alert for unusual denials," says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders' National Advisory Board.

Bonus: "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," Rosen said.

Updates: Like the NCCI edits, the MUE will be updated quarterly and be subject to continuing refinement.

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.