Pathology/Lab Coding Alert

Learn what to expect from latest procedure limits CMS won't publish the list of Medically Unlikely Edits (MUEs), but your lab won't get paid if you exceed the proscribed number of units.
 
MUE phase I passed with little notice because the January list included few 80000-level codes. But labs aren't so lucky with phase II (version 1.1), effective April 1, 2007. Bone Up on the New MUEs Background: Going from -unbelievable- to -unlikely,- the current MUEs are a refined version of the -Medically Unbelievable Edits- that CMS proposed -- and then withdrew due to provider concerns -- in 2005.
 
The goal: The new edits should prevent overpayments caused by gross billing errors, usually as the result of clerical or billing system mistakes, said Niles Rosen, MD, medical director for Correct Coding Solutions LLC -- which has worked with CMS to develop the current edits -- during a presentation at the American Medical Association's CPT and RBRVS 2007 Annual Symposium in Chicago.
 
What it means to you: -The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period,- Rosen said.
 
Warning -- provider liability ahead: Unlike other Medicare denials for screening tests or based on National Correct Coding Initiative (NCCI) edits, you cannot bill the denied service to the beneficiary -- even with a signed Advance Beneficiary Notice (ABN), says Pamela Younes, MHS, HTL (ASCP), CPC, PA (ASCP), assistant professor at Baylor College of Medicine in Houston.
 
Updates: Like the NCCI edits, CMS will update MUEs quarterly and continually refine the list of procedures and the units.
 
For more information on the MUEs, read MLN Matters Number MM5495 at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5402.pdf. Watch for More Subjective Edits Learn anatomical edits first: The first batch of MUEs -- effective Jan. 1 -- focused on anatomically impossible claims. Most of the edits limited surgical procedures based on anatomy, such as only one appendectomy per day because a patient has only one appendix.
 
Code descriptors drive phase II edits: Phase II edits should include limits that the code descriptors clearly indicate, according to CMS. For instance, a lab edit that is effective April 1 is four units of 82784 (Gammaglobulin; IgA, IgD, IgG, IgM, each). That's because four is the maximum number of times you would report the code if the lab tested for all four immunoglobulins, based on the word -each- in the code definition.
 
Other phase II edits focus on the nature of the testing equipment, the study or procedure, or the pathology specimen, according to Younes. For instance, CMS sets the MUE limit for Pap smear codes at one because the nature of the specimen is a single cervical or vaginal smear in most cases. [...]