Revenue Cycle

Q&A: Medically Unlikely Edits and Once in a Lifetime codes

Recovery Auditor Report, September 17, 2009

Q: Several RACs are looking for once in a lifetime procedure coding errors. Wouldn’t Medically Unlikely Edits (MUE) help prevent a large number of these errors?
A: According to CMS, an MUE is a unit of service edit for a HCPCS/CPT code for services provided by a single provider to a single beneficiary on the same date of service. The ideal MUE is the maximum unit of service reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. Examples include:
  • Code 23405 (Tenotomy, shoulder area; single tendon) has an MUE of 2
  • Code 43600 (Biopsy of stomach; by capsule, tube, peroral (one or more specimens) has an MUE of 1
  • Code 58260 (Vaginal hysterectomy, for uterus 250g or less) has an MUE of 1
(Click here to see CMS’ published list of MUEs. Note: CMS has not published all MUEs.)
A once in a life time code refers to codes for services or procedures generally performed only once during a patient’s lifetime. Examples include code 87902 (Genotype, hepatitis C), code 90989 (Dialysis training, completed course) or code 47600 (Cholecystectomy).
There are several differences, but one major issue relates to the timing. MUEs refer to services unlikely to occur on the same date of service, whereas once in a lifetime codes are unlikely to occur more than, well, once in a lifetime.
So an MUE may catch a once in a lifetime coding error if, for example, a computer glitch causes a provider to rebill all of the claims for a certain date—one of which contained a once in a lifetime code—a second time. However, if a once in a lifetime code is reported for a patient on different dates of service, the MUE would not catch the error.
Note that there are occasions when it may be appropriate to bill a once in a lifetime code on separate days, in which case a modifier should also be used. For example, a physician may begin a procedure but not be able to finish it due to problems with the patient’s blood pressure. The physician may then perform the same once in a lifetime procedure on a different day, in which case it is correct to bill for both procedures. However, modifier -73 or -74 would need to accompany the code for the uncompleted procedure.
Editor’s note: Thanks to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro and Stacey Levitt, RN, MSN, CPC, Director of patient care management at Lenox Hill Hospital, for assistance answering the previous question. To hear more from Kimberly and Stacey on RACs and once in a lifetime procedures, consider attending the "Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status, and the Role of Physician Advisors" in Atlanta October 26-27.

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