Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 19, 2006 PDF

Watch out for another layer of edits, coming soon

The Centers for Medicare & Medicaid Services seemed to have given up on the idea of "medically unbelievable" edits (MUEs) last year. (See PBI, Vol. 6, No. 11.) But now the MUEs are back--and they could be taxing you beyond belief.

CMS sent a draft of the MUEs to the specialty societies back in January, giving them two months to comment. However, the draft of the edits was so burdensome that the societies requested more time to comment--and CMS officials tell PBI that the agency is going back to the drawing board. A new draft will be circulating soon, and the societies will have longer to comment on them.

The revised version will reflect the comments CMS has already received on the draft it circulated in January, a CMS official tells PBI.

The MUEs were only supposed to cover situations that should never happen, such as "a hysterectomy in a male," CMS officials told the Practicing Physicians Advisory Council last week. The edits would prevent billing for millimeters of a medical product that's billed based on liters, or 60 services when the provider meant six services.

But CMS has expanded the MUEs to cover other issues. For example, the draft MUEs would deny claims for pathology charges for all but the first two biopsies. The standards of care call for six to 12 prostate biopsies, but Medicare would only pay for the first two.

PPAC recommended that CMS withdraw the proposed edits and publish a formal regulation seeking comment instead.

Outcome: CMS has promised to work with providers and allow them longer to consider its proposal. The agency won't impose the new MUEs before Jan. 1, 2007.