Corporate Compliance

Note from Hugh

Medicare Insider, March 18, 2008

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CMS conducted a Hospital Open Door Forum conference call last Thursday. A number of important operational issues were discussed. If you missed the call, you should try to catch the "encore" (i.e., recorded) version. It is available at no charge through tomorrow (Wednesday, April 19). Dial 800-642-1687 and enter 33267865 as the conference ID.

One issue that was discussed on the call was the so-called "medically unlikely edits" or "MUEs." The MUEs are a set of edits maintained by CMS's National Correct Coding Initiative (NCCI) contractor. They are designed to "edit out" outpatient services when the units of service billed seem to be "medically unlikely."

The MUEs have been controversial because, unlike the NCCI edits, CMS has not publicly released the MUE edits. However, the January 2008 update to the HCPCS Level II file added the following new modifier:

    GD: Units of service exceeds medically unlikely edit value and represents reasonable and necessary services

Interestingly, CMS has issued no guidance (or at least none that I can find) on when or how this modifier should be used. On last week's Hospital Open Door Forum conference call, a caller noted that her hospital had attempted to override MUE edits applicable to certain injection/infusion services with the new -GD modifier but the modifier did not appear to override the edits. The caller asked whether CMS would recognize the -GD modifier or issue a transmittal regarding its use. CMS responded that it would contact the caller to follow-up on this issue.

Where does this leave hospitals? First, we all need to be on lookout for guidance from CMS on the -GD modifier. In the meantime, hospitals will need to contact their local Fiscal Intermediary or Medicare Administrative Contractor (MAC) for guidance on the use of this new modifier.

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