Stakeholders Urge Thorough Review, Transparency

Most physicians wouldn't bat an eye over a new CPT code. But the prospect of more than 10,000 new CPT codes and Healthcare Common Procedure Coding System Level II codes got the attention of the Academy and 91 other medical associations and institutions.

The new codes are part of CMS' medically unbelievable edits, or MUE, program that was designed to prevent fraud and errors in the form of multiple billings for the same procedure.

The 92 stakeholders closed ranks and sent a letter to CMS Administrator Mark McClellan, M.D., Ph.D.

"We support CMS' efforts to reduce the Medicare error rate and believe that the appropriate use of unit edits to correct claims errors is a reasonable approach," said the April 10 letter. "However, we have serious concerns that CMS has underestimated the scope of review, the importance of accuracy and the need for detailed rationale and data behind these edits."

The letter spelled out four requests for McClellan's consideration.

Cynthia Hughes, AAFP's coding and compliance specialist, provided some additional background outside of the letter's content. She said the concept of medically unbelievable edits is a good one that has been used by some payers for years. "It was intended to prevent, for example, billing for three leg amputations on the same patient on the same day," she said.

However, said Hughes, the concern here is that CMS came out all at once with more than 10,000 codes. And, from the AAFP's perspective, because many of these are codes for services and procedures commonly provided by family physicians, an extension of the review time is in order.

Hughes emphasized that CMS proposed the new codes with no overriding modifier, which means physicians could, at times, not be paid for their services.

Consider this example, said Hughes. A patient complains of palpitations; the physician runs a three-lead electrocardiogram and diagnoses atrial fibrillation. The physician then attempts to convert the rhythm and performs a second three-lead ECG to determine if the patient's rhythm has returned to normal. Without the benefit of a modifier for the code 93040, the physician would be paid for only one of the two ECGs performed on the date.

Organizations signing the letter ranged from the AMA to the Albert Einstein College of Medicine, Bronx, N.Y., to the Medical Group Management Association.