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Medically Unlikely Edits by Medicare

  1. Question Medically Unlikely Edits by Medicare
    Medical Coding Books
    A chemo patient received her Chemo, then 2 push medications and 5 subsequent infusions, all in different bags. I am getting a MUE edit stating that only 3 units can be billed for code 96367 and not 5. The way I feel about this code is that it is medically unlikely, but that doesn't mean it won't happen and it can be billed with 5 units, our compliance person is telling me that I cannot bill for the 5 units, it has to be changed to 3. Has anyone else had this problem? Your thoughts and knowledge on this matter would be greatly appreciated.

  2. Default
    Quote Originally Posted by paco5542 View Post
    A chemo patient received her Chemo, then 2 push medications and 5 subsequent infusions, all in different bags. I am getting a MUE edit stating that only 3 units can be billed for code 96367 and not 5. The way I feel about this code is that it is medically unlikely, but that doesn't mean it won't happen and it can be billed with 5 units, our compliance person is telling me that I cannot bill for the 5 units, it has to be changed to 3. Has anyone else had this problem? Your thoughts and knowledge on this matter would be greatly appreciated.

    Did you have more than one initial site? I would think that if you had 5 lines running they were in two arms. I would appeal if there were 2 initial sites and one had a modifier.

  3. #3
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    What drugs are you billing out? What code did you use as your initial?

  4. #4
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    Medicare has implemented MUEs as of 01/01/12 limiting the 96367s to 3 max. The Community Oncology Alliance (COA) had requested a review of this decision and that the edit be rescinded as soon as possible. As of today, the edit will be at least "temporarily suspended officially at the end of the first quarter, with payment updates retroactive to January 1, 2012 on those claims not paid." Hang in there and good luck!

  5. Default Coding Help on MUE Relating to CPT Code 96367
    Just received this information today in an email. Here is the link also
    http://communityoncology.org/Templat...ode-96367.aspx

    Coding Help on MUE Relating to CPT Code 96367
    During a recent national call of the COA Administrators' Network (CAN), the issue of Medicare payment problems associated with CPT code 96367 was raised. Many practice administrators expressed concern over the rejection of submitted claims that contained more than three (3) sequentially infused drugs during one visit/occurrence. It was then learned that the Centers for Medicare and Medicaid Services (CMS) had put in place a Medically Unlikely Edit (MUE) effective January 1, 2012, limiting sequential infusions to a maximum of three substances.

    COA is pleased to report that based on the MUE problem raised on the CAN call, and subsequent input from several practices, the MUE is being changed. We have had numerous communications with Dr. Niles Rosen at the National Correct Coding Initiative (NCCI), which administers the MUEs for CMS. Dr. Rosen sent us the following:

    “We have had further discussion with CMS which owns MUE and determines its contents. We will make a temporary change in the MUE value for this code in the April 1, 2012 version. The change will be retroactive to January 1, 2012. The new value, like the previous value is a confidential, unpublished value but is high enough to allow for the three examples that you provided. If your members choose to hold their claims until April 1, 2012, their claims will be adjudicated against the new value. Alternatively, until April 1, 2012, your members reporting more than 3 UOS (units of service) of medically reasonable and necessary sequential infusions of new drugs/substances can use the method that I previously described reporting the code on two lines of a claim appending modifier 59 to the code on one line and dividing the total UOS between the two lines.”

    So, you have 2 courses of action: Hold your claims until April 1, 2012 or follow the work-around provided by Dr. Rosen as follows:

    CMS requires that claims processing contractors adjudicating claims deny an entire claim line if the provider reports units of service that exceed the MUE value for the code on the claim line. A provider may appeal the claim line denial to his local claims processing contractor. Alternatively, if the provider plans to report medically reasonable and necessary UOS in excess of the MUE value, the provider may report the code on two claim lines using modifier 59 appended to the code on one claim line and divide the UOS between the two claim lines. The MUE value for this code is adjudicated against each claim line separately. Thus, the provider could report up to six UOS for this code on two claim lines without hitting the MUE.

    If you have any questions about this please contact Mary Kruczynski, Director of Policy Analysis at COA at maryk@COAcancer.org.

    This is just one example of the power of sharing information among administrators and working together. If it had not been for the COA Administrators' Network members, who truly are hands-on in the billing and reimbursement arena for oncology, the concern over the impropriety of this MUE would not have been raised at all. We have requested that COA be included in the MUE review process to correct mistakes before they are made, as in this case. In fact, NCCI and CMS have asked to meet with us to discuss these issues, which we will be doing.

  6. #6
    Location
    Everett, WA
    Posts
    887
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    Many thanks for sharing this invaluable information. It's great to be able to address these issues on the front side of sending claims and will serve our practice well! ---Suzanne E. Byrum CPC

  7. Default Mue 96367
    Thank you everyone that responded to my question regarding MUEs for 96367. Your help and information is greatly appreciated.

    Rose Shreve, CPC

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