Part B Insider (Multispecialty) Coding Alert

Published on Wed Jan 26, 2005 PDF

Brand new edits could cut back the number of times you can bill each code

You could soon find yourself playing Believe-It-Or-Not with Medicare over your usage of certain codes.

The Centers for Medicare and Medicaid Services announced in Transmittal 105, issued Feb. 18, that it hired Adminastar Federal to develop new "medically unbelievable" edits (MUEs). These edits will target usages of particular codes that seem hard to believe according to Adminastar's number crunchers.

Here's how it works: The National Correct Coding Institute ( NCCI) edits normally list a code in each of two columns. Instead, 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.

Carriers have had frequency edits in place for years, notes consultant Quinten Buechner with ProActive Consultants in Cumberland, WI. So this new development may simply add more transparency to existing practices - or it may go much further and confuse providers with each quarterly update. We'll know more once CMS publishes a "Medlearn Matters" article about the MUEs.

The new MUEs may simply standardize the existing edits across all carriers, says Barbara Cobuzzi, president of Cash Flow Solutions in Cherry Hill, NJ. The NCCI already bundles surgical codes with themselves, meaning they're limited to one unit of each code, she notes.

Buechner offers a few examples of things that are likely to be hit with MUEs: two subsequent hospital visits on the same day, excessive doses of drugs such as 10,000 units of Lupron, more than five or six Complete Blood Count tests, or 15 X-rays of the same finger.

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, IL.

"It's going to be stuff that you don't expect" physicians to be doing, Buechner explains. Many of the edits will probably target typographical errors, such as having 10 units instead of 1.0 units. He also cites physical therapy services, which CPT divides into 15-minute increments - and nobody expects to see a patient having 150 minutes of physical therapy per day.

Likewise, there will probably be a limit on the number of lesions you can bill for, Cobuzzi says. But this could indirectly raise operating costs, because a physician might choose not to remove all of a patient's lesions on a particular day for fear of triggering these edits. The physician will have to come back on another day and remove the rest.

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.