CMS finally publishes long-awaited list of medically-unlikely edits.
Plan administrators can now better assure that Medicare providers and suppliers do not report excessive services. Despite the Centers for Medicare & Medicaid Services’ insistence that it would not publish its list of medically-unlikely edits, CMS changed course and published the listing on Oct. 1.
MUEs check the number of times a provider or supplier reports a service for the same patient on the same date of service. CMS first implemented the MUE program on Jan. 1, 2007 with edits for about 2,600 HCPCS/CPT codes, and there have been quarterly updates since then adding additional codes.
This latest version starting Oct. 1 will contain edits for about 9,700 HCPCS/CPT codes that have been assigned unit values for MUEs. CMS will publish most of the MUEs active for that quarter at the start of each calendar quarter. The Oct. 1, 2008 publication will contain most, but not all, MUEs.
Additional ones will follow Jan. 1, 2009. CMS won’t publish all active MUEs, as some are meant to detect and prevent fraud rather than billing errors, and CMS would prefer to keep those cards close to its chest for obvious reasons.
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 CCI edits in that it does not include code pairs. Instead, it lists specific CPT or HCPCS codes, followed by the number of units that CMS will pay. For example, the MUEs allow providers to report only one unit of 40800 (Drainage of abscess, cyst, mematoma, vestibule of mouth; simple). They can, however, report two units of code 40818 (Excision of mucosa of vestibule of mouth as donor graft).
Important: The list of MUEs on the CMS Web site is not entirely complete. “The published MUE will consist of most of the codes with MUE values of 1-3,” the Oct. 1 notice indicates. “CMS will not publish all MUE values that are 4 or higher because of CMS concerns about fraud and abuse,” it states.
What to expect: The MUEs probably won’t offer too many surprises, with the surgical codes featuring the most MUEs and the anesthesia code series with the fewest.
Following is a sampling of codes that allow one, two, or three units billed to Medicare:
Indicator of 1: Providers can report just one unit of the following codes before the MUEs kick in:
• 11100 -- Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion
• 42809 -- Removal of foreign body from pharynx
• 37600 -- Ligation; external carotid artery
• 99201-99211 -- Office or other outpatient visit.
“It’s a little bit surprising that the other established patient E/M codes from 99212-99215 aren’t on the MUE list,” says Alexis Riegel with Anderson Family Practice. “But then again, CMS says it didn’t list all of the MUEs in the file.”
Indicator of 2: Providers can report two units of the following codes before the MUEs kick in:
• 29877 -- Arthroscopy, knee, surgical; debridement/shaving of articular cartilage chondroplasty)
• 43760 -- Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance
• 62142 -- Removal of bone flap or prosthetic plate of skull
Indicator of 3: Providers can report three units of the following codes before the MUEs kick in:
• 77781 -- Remote afterloading high intensity brachytherapy; 1-4 source positions or catheters
• 86382 -- Neutralization test, viral
• L3933 -- Finger orthosis, without joints, may include HCPCS soft interface, custom fabricated, includes fitting and adjustment.
To read the complete list of MUEs or to find out more about the MUE program, visit the CMS Web site at www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage.