Health Information Management

Tip: Note new medically unlikely edit categories

APCs Insider, April 12, 2013

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CMS recently changed some medically unlikely edits (MUEs) from line-item edits to date-of-service edits. CMS is dividing the new MUE edits into two categories.

The first is codes that will almost never be reported with more units of service than the MUE. For example, providers would almost never report CPT code 33945 (heart transplant, with or without recipient cardiectomy) with more than one unit of service.
 
The second is codes that will rarely exceed the unit of service MUE. For example, typically providers would only ever report one unit of service for CPT code 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). In certain specific cases, a provider may need to perform a second hysterectomy for a patient with a double uterus.
 
Based on CMS' communication, it seems unlikely that providers will be able to bypass the new DOS MUEs using modifiers as they've been able to do up until now, but providers won't know for sure how claims are processed after April 1.
 
The tip is adapted from “CMS changing MUEs” in the April Briefings on APCs.



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