General Surgery Coding Alert

CMS delivers on long-promised initiative

Ready yourself now: 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 -- from CMS.

If the edits function as intended, however, you should find them more a help than a hindrance to your practice.

Edits Prevent Gross Mistakes

The new -Medically Unlikely Edits- (MUEs) are an undated and refined version of the -Medically Unbelievable Edits- that CMS initially proposed -- and then, due to provider concerns, withdrew -- in 2005.

The goal of the new edits is to prevent overpayments caused by gross billing errors, usually as the result of clerical or billing systems mistakes, said Niles R. Rosen, MD, medical director for Correct Coding Solutions LLC, which has worked hand-in-hand with CMS to develop the current edits, during a presentation at the AMA CPT and RBRVS 2007 Annual Symposium in Chicago.

Rosen cites an example of a single CT scan that was billed (and inappropriately paid) as 10,001 units of service, as well as a shoulder arthroscopy billed as 141 units of service. -The number 141 was actually the minutes of anesthesia,- he said.

Such inappropriate claims were not the result of outright fraud, but simply serious blunders on the part of the billing providers.

-The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period,- Rosen said. The maximum units of service for a given CPT code have not been assigned arbitrarily, but by using common-sense criteria.

Example: 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.

Likewise, the MUEs would limit the number of simple repair codes (12001-12021) per anatomic location that you may bill per claim. Again, this makes sense because you should combine the lengths of the various repairs of the same type and location into a single code. Therefore, for instance, you would never code for simple repairs of the trunk using both 12001 (- 2.5 cm or less) and 12004 (- 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 12005, - 12.6 to 20.0 cm).

Although this is just a single example, other edits will follow similar logic.

Edits Operate per Line, Not per Claim

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 for the single line item that violates the MUE guidelines, Rosen said.

In addition, you will be able to appeal MUE-based rejections if you feel that your claim was appropriately billed and meets the requirements of medical necessity.

-However,- Rosen said, -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.- 

Like the NCCI, CMS will update the MUE quarterly, and they will be subject to continuing refinement. -CMS and Correct Coding Solutions welcome suggestions and comments from providers,- Rosen said.

More details to follow: The first edits were not available when this article went to press -- and at least one CMS spokesman has advised that the edits will not be published or posted on the CMS Web site. Keep watching General Surgery Coding Alert for additional information on the MUEs as it becomes available.