General Surgery Coding Alert

Sometimes you can override edits or appeal claims.

If you get claims denials for your general surgeon’s work based on CMS’s medically unlikely edits (MUEs), do you just sit down and take it?

We have expert tips to help you fight back. Read on to learn 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, explainsChandra 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: Know the Edits that Impact Your General Surgery Practice

The published CMS MUE list includes unit limits for thousands of CPT^® codes. You’ll need to study the list to see which MUEs are of most concern to you based on which procedures your general surgeons frequently perform.

Some common general surgery codes and their MUE limit (in parentheses) are as follows:

• 11646 —Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm (3)
• 13100-13152 — Repair, complex … (1)
• 19101 — Biopsy of breast; open, incisional (3)
• 19301 —Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy) (1)
• 24071 — Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater(3)
• 36556— Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older (2)
• 38510 — Biopsy or excision of lymph node(s); open, deep cervical node(s)(1)
• 43611 — Excision, local; malignant tumor of stomach(1)
• 44140 — Colectomy, partial; with anastomosis(2)
• 46945 — Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group(1)

Tip 3: Learn the Override Possibilities

If a patient’s record indicates medical necessity for each procedure your surgeon performs, even if it’s subject to an MUE, you can override the edits.

For instance:If your surgeon excises four distinct soft tissue tumors from different sites of the upper arm, you can report four units of 24071 using an appropriate modifier even though the code has an MUE limit of three.

Claims tools: You can use a 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), 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 surgeon’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.