Pathology/Lab Coding Alert

Discover guidelines to legitimately override edits or appeal claims.

CMS’s theory behind medically unlikely edits (MUEs) sounds innocent enough: to reduce the paid claims error rate for multiple service units based on anatomic considerations, code descriptors and instructions, and CMS policies. But in practice, MUEs can place a roadblock in the way of your valid lab and pathology claims.

Follow our four expert tips to make sure you know when to stop at the MUE limit, and when and how you can hurdle over an MUE obstacle to capture all the pay you deserve.

Tip 1: Grasp The MUE Program

MUEs “limit the frequency a CPT^® code can be used,” for one patient on one date, explains Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC.

Each MUE deals with the maximum number of units of service you can bill for a single code. That’s different from Correct Coding Initiative (CCI) edits, which relate to code pairings (whether two codes can be billed together), 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.

History: “The first MUEs were implemented in January 2007, although the list of edits themselves became public only in October 2008,” says Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, president of Comply Code in Binghamton, N.Y.

CMS publishes a quarterly list of MUEs that “includes specific CPT^® or HCPCS codes, followed by the number of units that CMS will pay,” Harrington says. You can find the current list at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html.

Note: Despite publishing a list of MUE edits, the list is not comprehensive. “The published MUE [list] will consist of most of the codes with MUE values of 1-3,” according to CMS. The agency goes on to state that, “CMS will not publish all MUE values that are 4 or higher because of CMS concerns about fraud and abuse.”

Tip 2: Get Familiar With Edits that Impact Your Lab

The published CMS MUE list includes unit limits for over 1000 pathology/laboratory CPT^® codes. You’ll need to study the list to see which MUEs are of most concern to you based on which procedures your lab frequently performs.

Some common lab and pathology codes and their MUE limit (in parenthases) are as follows:

80047 — Basic metabolic panel … (2)

80500 — Clinical pathology consultation; limited, without review of patient’s history and medical records (1)

81001 — Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy (2)

84165 — Protein; electrophoretic fractionation and quantitation, serum (1)

85025 — Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count (2)

86355 — B cells, total count (1)

87040 — Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) (2)

88104 — Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation (4)

88141 — Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician (1)

88173 — Cytopathology, evaluation of fine needle aspirate; interpretation and report (3)

88187 — Flow cytometry, interpretation; 2 to 8 markers (1)

88302 — Level II - Surgical pathology, gross and microscopic examination … (2)

88331 — Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen (11)

Tip 3: Learn the Override Possibilities

If a patient’s record indicates medical necessity for each test your lab performs, even if it’s subject to an MUE, you can override the edits. Diagnosis codes, physician orders, and descriptions of distinct tests or specimens could satisfy the medical-necessity documentation. For instance, if the pathologist diagnoses and reports on fine needle aspirate (FNA) specimens from four different sites, you can report four units of 88173 the code has an MUE limit of three.

Claims tools: You can use an appropriate modifier to override an MUE limit when documentation demonstrates medical necessity for the number of units performed. Because CMS evaluates each claim line against the MUE value, you’ll need to list the same code on separate claim lines with the appropriate modifier.

You can override “medically reasonable and necessary units of service in excess of an MUE value” using a CPT^® modifier such as 76 (Repeat procedure by same physician), 77 (Repeat procedure by another physician), 91 (Repeat clinical diagnostic laboratory test), or 59 (Distinct procedural service), or anatomic modifier (such as RT, LT, F1, F2).

Skip the ABN: For claims denied due to an MUE, you cannot use an advance beneficiary notification (ABN) to transfer responsibility for payment to the beneficiary, Harrington warns. CMS makes this rule very clear in its FAQs, stating: “A provider/supplier may not issue an ABN for units of service in excess of an MUE. Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability and bill the beneficiary for the denied services. It is a provider/supplier liability.”

Tip 4: Focus on Appeal Options

If you receive a claim denial due to MUEs, follow these steps to a correction, an appeal, or MUE change:

First step — 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.

Second Step — decide if you have a legitimate reason to appeal: Review the lab’s documentation to determine if you have a case for medical necessity for the services over and above the allowable units under the MUE.

Third step — appeal the claim: If you have adequate documentation, file an initial appeal with your Medicare contractor, providing the best documentation available. For instance, “if you’re appealing the claim due to a clinical reason, you may wish to employ clinical expertise when putting together your appeal letter,” Harrington suggests.

You can continue your appeal through the standard five-level Medicare appeals process, if necessary: redetermination, reconsideration, administrative law judge, appeals council and judicial review.

Fourth step — try to change the MUE: “Just because you win an appeal, you will not change the MUE edit,” Cobuzzi warns. “To get the MUE changed, you need to go to your Carrier Advisory Committee (CAC) and your payer’s medical director.”

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.