Urology Coding Alert

Despite CMS reversal, experts say 'medically unbelievable' edits coming

You won't have to play Believe-It-or-Not with Medicare over your usage of certain codes right away. But the introduction of a new batch of coding edits is a question of "when," not "if," CMS insiders say.
 
Many coders have already seen Transmittal 105 from CMS, issued Feb. 18. Medicare hired AdminaStar Federal to develop new "medically unbelievable" edits (MUEs),  the transmittal said. These edits will target usages of particular codes that seem hard to believe, according to AdminaStar's number crunchers.
 
Shortly after releasing it, however, Medicare rescinded the transmittal. But that doesn't mean you still shouldn't get ready for MUEs - experts say these edits are still on the way, after some modifications.
 
Here's how it works: The National Correct Coding Initiative edits normally list, in two columns, pairs of codes that you cannot report together. Instead of two codes, however, the new edits will have a code in column A and a maximum number of code units that you can bill per day in column B.
 
The new MUEs may simply standardize the existing edits across all carriers, says Barbara Doll, RN, CPC, urology coding specialist with Healthcare Information Services in Willowbrook, Ill. The NCCI already bundles surgical codes with themselves, meaning they're limited to one unit of each code, she says.

Add MUEs to Existing Edits

Carriers have had frequency edits in place for years, says consultant Quinten Buechner with ProActive Consultants in Cumberland, Wis. So the edits, when they arrive, may simply add more transparency to existing practices - or they may go much further and confuse providers with each quarterly update.
 
Buechner offers examples of things that are likely to be hit with MUEs: two subsequent hospital visits on the same day, or excessive doses of drugs such as 10,000 units of Lupron.
 
Also, the edits are likely to target things like providers billing more than the maximum hours allowable (or possible) in a day, speculates Robyn Lee with Lee-Brooks Consulting in Chicago.
 
"It's going to be stuff that you don't expect" physicians to be doing, Buechner says. Many of the edits will probably target typographical errors, such as having 10 units instead of 1.0 units.
 
Conflict on the way? Buechner expects to see arguments about some of these new edits. For example, if two different physicians see a patient on the same day and they each bill 99214 for their visits, the edits may deem that excessive. But if the patient is in bad enough shape, his condition could easily justify both units of 99214.
 
Keep checking Urology Coding Alert for more information as soon as Medicare announces further plans for these edits.

Correction

An article in the April 2005 Urology Coding Alert, "Believe It or Not: Add Frequency Bundles to NCCI," erroneously cited Barbara Doll, RN, CPC, urology coding specialist with Healthcare Information Services in Willowbrook, Ill.
 
She did not, in fact, provide this specific information; it should not have been attributed to her.
 
We apologize for our error.