CMS Improves Medically Unlikely Edit Program

CMS has reversed an earlier decision to keep billing edits in its Medically Unlikely Edit, or MUE, program, under wraps. After receiving pressure from the AAFP and dozens of other medical organizations, the agency has pledged to make most of those edits public, which means that when family physicians question a Medicare claims denial, they'll have access to the information they need to appeal MUE criteria.

CMS published the first batch of billing edits on Oct. 1, and, according to a CMS press release, the agency will publish edits quarterly.

The MUE program was initiated by CMS in 2006 and implemented in 2007 as a way to improve the accuracy of Medicare Part B claims payments to physicians and other Medicare providers. The edits are applied during electronic processing of claims to ensure Medicare providers and suppliers do not report excessive services.

About a year ago, the Academy urged CMS to honor its commitment to foster transparency in the MUE program in a letter to CMS and its coding contractor. (2-page PDF; About PDFs) In the letter, (then) AAFP Board Chair Larry Fields, M.D., of Flatwoods, Ky., noted CMS' failure to release the edit criteria, and he chided CMS for assuming ill intent regarding billing errors "due to the egregious acts of a very limited number of physicians and providers." Fields pointed out that by CMS' own admission, typographical errors -- not intentional abuse of the system -- accounted for the majority of claims errors.

Fields also argued that according to CMS' own 2007 report, there was only a 3.8 percent overpayment rate among all fee-for-service contractors. He suggested that making edit criteria available to the public would encourage software vendors to build the criteria into practice management systems. Those systems likely could then be enabled to alert physicians to claims payment errors before claims were sent to Medicare.

Cynthia Hughes, C.P.C., an AAFP coding and compliance specialist, said many of the MUEs cover surgical procedures -- such as mastectomy -- and, therefore, do not even apply to family physicians.

On the other hand, said Hughes, it's relatively easy to make coding errors in a busy family medicine practice. For example, CPT code 11055 should be used for the paring or cutting of a single benign hyperkeratotic lesion. "If a physician billed two units for that code, he would get a Medicare denial because two to four lesions should be coded with CPT code 11056," she said.

According to CMS' latest statement, the agency plans to withhold from publication those edits that are "primarily designed to detect and deter questionable payments rather than billing errors" because "publishing those MUEs would diminish their effectiveness."

CMS has not yet determined if the MUE program has resulted in any savings to Medicare.