Part B Insider (Multispecialty) Coding Alert

Published on Fri Aug 18, 2006 PDF

2,800 edits target 'non-controversial' topics

A drastically unpopular set of edits is back for yet another go-around.

The Centers for Medicare & Medicaid Services almost scrapped the controversial medically unbelievable edits (MUEs) but instead renamed them medically unlikely edits.

Either way, they-re still designed to test particular codes against a maximum number of units of service. These edits will auto-deny or auto-suspend any claims where the units exceed the maximum. The carrier staff won't review these denials unless there are limitations in the shared system.

The approximately 2,800 new edits will apply to -non-controversial- anatomic considerations, CMS says.

Good news: The MUEs won't apply to all services, CMS says in Transmittal 155. For example, CMS has no plans to develop MUEs for anesthesia services. CMS also says it will set the maximum units high enough for each service to allow -medically reasonable daily frequencies of clinical outpatient services provided in most outpatient or provider settings.-

You can bring any concerns you may have about a particular MUE to the Correct Coding Initiative coordinator, AdminaStar Federal.

Note: You can't bill your patient for any excess charges denied by the MUEs, CMS clarifies. You also won't be able to appeal these denials.

In other news:

- A Miami physician received a 65-month prison sentence, plus three years- supervised release and a $1.3 million repayment, for his part in an AIDS clinic scheme. Prosecutors said Isaac Nosovsky pre-signed medical agreements in 2004 and 2005, indicating that he-d treated patients at a clinic when he hadn-t. Evidence at his trial showed he received around $160,000 for four months- participation in the scheme. The Federal Bureau of Investigation also just arrested Miami physician Frantz Achille for participation in the same scheme.

- Carriers and other Medicare contractors should make sure they don't go after the same physicians as the Recovery Audit Contractors (RACs), CMS says in Transmittal 104. The carriers should communicate with the Medicare -bounty hunters- to make sure they don't try to recover the same overpayments, CMS adds.

- Medicare should pay for telehealth services in a critical access hospital (CAH) at 80 percent of the Medicare physician rate, CMS said in Transmittal 1026.

- If your physician dispenses durable medical equipment, prosthetics, orthotics or supplies (DMEPOS) out of the office, you should look at the new DMEPOS quality standards, now online at www.cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_Standards.asp.

- Starting Oct. 1, CMS will only issue electronic remittance advice (ERA) notices that comply with the Health Insurance Portability and Accountability Act (HIPAA).