Pathology/Lab Coding Alert

Find out why Medicare denies your second slide consult. The once-secret limit to the number of units Medicare will cover for a given lab procedure is out of the shadows -- mostly. Despite the agency's insistence that it would not make public the medically-unlikely edits (MUEs), CMS changed course and published the list on Oct. 1. Caveat: The list of MUEs on the CMS Web site is not entirely complete. The published list "will consist of most of the codes with MUE values of 1-3, - [but not] MUE values that are 4 or higher because of CMS concerns about fraud and abuse," according to Kimberly Brandt, CMS Director, Program Integrity Group, in an open MUE publication announcement letter. Brandt continues, "A minimal number of MUEs with lower values that are believed by CMS to be particularly vulnerable to fraud and abuse may not be published." Take-home lesson: If a code isn't on the MUE list, that doesn't mean it is not subject to an MUE limit. 88305 MUE Scare Although CMS proposed limits to certain surgical pathology codes in the past, such as 88305 (Level IV - Surgical pathology, gross and microscopic examination) and 88307 (Level V - Surgical pathology, gross and microscopic examination),neither of the codes are on the published MUE list. Beware WPS experience: Earlier this year, however, Wisconsin Physicians Service (WPS) began denying 88305 and 88307 claims with more than one unit, according to Stan Werner, MT (ASCP), administrative director of Peterson Laboratory Services, PA, in Manhattan, Kan. "Although the intermediary stated that the denials were due to an MUE limit of one for the codes, we were told to bill each as a separate line item with modifier 76 (Repeat procedure by same physician) if we could show medical necessity for the multiple units," Werner says. All's well that ends well: "WPS eventually discontinued the edit, and we-re not receiving the denials at this time," Werner says. We hope -: The WPS experience has left questions about whether 88305 and 88307 might be part of the "unpublished" MUEs -- and that has pathologists concerned. Here's why: Multiple units of 88305 are often medically necessary, such as when pathologists examine multiple distinct skin or prostate biopsies and correctly report several units of 88305 on the same day. Learn MUE Rationale and Format The MUE program aims to help CMS "dramatically reduce costly payment errors," said CMS Acting Administrator Kerry Weems in an Oct. 1 statement. However, the news release acknowledges that "CMS has not yet determined if there have been any savings in the MUE program since it was implemented" in January of 2007. The MUE list differs from standard Correct Coding Initiative (CCI) edits in that it [...]