The following was put out by Bobbie Buel (The Coding Mistress) in her E-Reimbursement newsletter Issue #3, Volume 20. Good Luck!
[[["MUEs Mauling Claims
Okay, this is something I thought was an accident waiting to happen for awhile. And, now the MUEs have struck common cancer drugs like fulvestrant, epoetin alfa, 5-FU, and others. Here's the deal..CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE. MUE was implemented January 1, 2007 and is utilized to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs.
Most MUE edits are adjusted and published on a quarterly basis, so you can know when claims are going to hit a 'hard edit'. But, J-code edits are kept secret, so you can be nailed without a forewarning. MUEs are supposedly approved by specialty societies, but that is not necessarily true of the most secret, confidential MUEs. Sounds sort of like the Ayatollah of coding, doesn't it?
The most egregious example of the MUE travesty is the hard edit on fulvestrant, J9395 for 25 mg. This edit kicks out any claim with over 10 units billed. Last summer, fulvestrant's 500 mg. dosing was approved by the Food and Drug Administration, meaning 20 units is an FDA-approved dosing---but, as of 1/1/2011, you can't bill it. Reportedly, because ASCO and COA have been on this, this edit may be fixed in the next iteration of these MUEs (4/1/2011). But, what happens in the meantime?
You can hold claims, if you are positive the fix is in...but who wants to?? CMS advises that erroneously edited claims are appealed to your local MAC. If you need an appeal letter for fulvestrant, we have one for you along with the FDA approval right in the middle of the COA web site. You can also call the fulvestrant hotline at 866-992-9276. For other drugs, you can also appeal those to your local MAC. Your MAC cannot fix these edits. These edits are assigned by Correct Coding Solutions LLC, the contractor for the Cruel Coding Initiative (CCI) and the MUEs. They only take appeals from specialty societies (and they have heard from ASCO and COA), but, believe me, if the MACs are flooded with appeals, they'll be hearing from CMS! So, appeal your claims!
In separate (but related) item this week, the OIG (the Oy General) released a report (A-06-10-00024) called 'Review of High-Dollar Payments for Medicare Outpatient Claims Processed by TrailBlazer Health Enterprises, LLC, for the Period January 1, 2007, Through December 31, 2008". This report reviewed six claims that amounted to $311,109 in recoveries for the reviewers---they were all wrong HCPCS units of service for drugs or wrong J-codes. Expect these edits and RAC reviews of drug units to continue and increase... "]]]