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CMS to modify medically unlikely edit (MUE) for CPT code 90766 in April

APCs Weekly Monitor, March 7, 2008

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QUESTION: Our fiscal intermediary (FI) has been returning claims that contain CPT code 90766 for IV infusion, additional hours/units greater than eight. The FI has returned these claims to provider (RTP), and we have seen edit 31715, which states the following:

Dates of service on and after 01/01/07; it has been determined the units of service are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary, and this provision can neither be waived nor subject to an advanced beneficiary notification (ABN). Please verify billing, and, if appropriate, correct.

We called our FI, and they indicated that they were aware of the edit and had investigated the problem. The FI also specified that there is not a formal outpatient edit for code 90766; however, there is a medically unlikely edit (MUE). They did not offer further explanation or guidance on this topic.

This edit appears on accounts that include additional infusion hours greater than eight-particularly observation cases that span several calendar days. When the reported date of service includes an infusion that is greater than eight hours, this triggers an edit, and the claim electronically bounces back to our billing staff for correction.

Can you provide guidance on this issue?

ANSWER: Let us introduce our newest member to the APC Weekly Monitor, Denise Williams, RN, CPCH, CDM, Director of Vanguard Health Systems who investigated and provided the most up-to-date information regarding this issue. CPT code 90766 has been a topic of discussion among FIs, Medicare Administrative Contractors, and CMS staff. Each has explained that they take responsibility for the edit and that they will be offering a solution April. We have discussed the edit with several FIs and MACs and also posed a question to the National Correct Coding Initiative (NCCI) administrator. The following is an excerpt from a letter that was sent in response to an inquiry to the NCCI administrator.

Codes 90761, 90766, and 90772-MUEs are confidential and for CMS and CMS' contractor use only. CMS does not authorize the MUEs to be released or shared with the general public or outside organizations. Based on new information, the MUE for these codes will be modified on April 1, 2008 and made retroactive to the original effective date of January 1, 2008. A provider may wish to submit the claims which have been returned for these codes after April 1, 2008.

We contacted CMS, and this inquiry was sent to Correct Coding Solutions, LLC (CCS LLC)-the contractor for CMS that evaluates the appropriateness of MUE levels set by CMS when requested by third parties.

A correction will not emanate until April 1. Therefore, we recommend that facilities approach this problem with their revenue cycle team and finance department to determine the appropriate operational process. For example, will you hold claims until the fix comes through or do you downgrade the units to eight? Provider options are not optimal, and hospitals must make team decisions rather than use a "silo" approach. Continue to monitor this problem with your FI and billers.

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