Part B Insider (Multispecialty) Coding Alert

Published on Sun Nov 26, 2006 PDF

'Medically unbelievable' edits shouldn't cramp your style

You may be able to use a modifier to override the new “medically unbelievable” edits (MUEs), the Centers for Medicare & Medicaid Services says in a statement.

The MUEs are just supposed to prevent “obviously erroneous” claims, and aren’t intended to be a new payment policy, CMS insists. CMS will work with providers to develop the statistical basis of these edits, and may let you override them for “clinical outliers.” CMS may also provide an appeals process if you receive an MUE-related denial.

CMS announced that the due-date for MUE comments has been extended to June 19, 2006. As reported last week, the MUEs won’t take effect until next January at the earliest. CMS says this will allow for another round of comments on a revised set of MUEs this fall.
 
In other news:

• You can expect another wave of confusion over the Part D drug benefit from patients who are being passively enrolled in drug plans. CMS has started mailing letters to 1.2 million low-income people,  letting them know which drug plan they’ve been enrolled in. The  recipients include people enrolled in other federal assistance programs such as Supplemental Security Income and Medicare Savings Programs, as well as beneficiaries who have applied for and been approved for a low-income subsidy for the Part D benefit.

• Manhattan doctor David Wexler was sentenced to 20 years in federal prison for distributing prescription narcotics (such as Dilaudid, Percocet, Vicodin, and Xanax) and for health care fraud. A jury found he billed various insurers for thousands of excision procedures that he didn’t perform, and either paid patients to lie, or provided them with drugs. Wexler billed Medicare for nearly 2,000 surgeries on Barry Abler, who died of an overdose from drugs Wexler provided. These included 1,300 four-cm excisions on Abler’s face alone, prosecutors say.

• The U.S. Senate passed a budget resolution March 16 that includes no cuts to Medicare, Medicaid or other entitlement spending programs. The Senate  narrowly rejected an amendment from Sen. John Cornyn (R-TX) that called for $10 billion in cuts over five years for programs including Medicare.

• Two Delaware physicians and Beebe Medical Center agreed to pay $1 million to settle charges that the hospital paid the doctors a fee on top of their Medicare reimbursements to treat patients at the hospital, according to The News Journal. “We thought we were doing it right,” an attorney for one of the doctors said. “There was no effort to hide it.”