For 2015, the U.S. Centers for Medicare and Medicaid Services (CMS) added a new feature to the National Correct Coding Initiative (NCCI) edits that hospital and physician office staff should understand. The NCCI edits now incorporate several other types of edits, including medically unlikely edits (MUEs) which incorporate three new MUE adjudication indicators (MAIs).
The MAIs identify the type of and rationale for the MUE. They let radiologists and other providers know whether the MUE is a claim-line edit or a date-of-service (DOS) edit based on policy or clinical benchmarks. Each of the MAIs has a different rationale as explained below, with radiology procedure examples included to further clarify. When it is appropriate to bypass an edit, be sure to check with your Medicare administrative contractor (MAC) for their modifier guidelines.
MAI of 1: Claim-line edit
A modifier may be appended to the code when the MUE value is associated with the MAI of 1. Each claim line is adjudicated separately against the MUE value for the Healthcare Common Procedure Coding System (HCPCS) code on that line. As long as documentation supports the procedure being performed more times than the MUE value, report the code multiple times on separate lines with an appropriate modifier.
Example
A patient has two transplanted kidneys and both are evaluated with grayscale and color Doppler ultrasound and spectral analysis for blood flow. The following code is assigned for each exam:
- 76776: Ultrasound, transplanted kidney, real-time and duplex Doppler with image documentation
- 76776-XS (or -59, -76, etc.)
If 76776 was billed on one line with two units of service (UOS), or billed with modifier -50 (bilateral), the claim would be denied. By billing 76776 twice, on separate lines, each line item meets the MUE of 1 and both would be paid.
MAI of 2: Date-of-service edit
This is based on policy (i.e., statute, regulation, or subregulatory guidance) or instructions that are inherent in the code descriptor. Neither MACs nor modifier assignment can override this edit. If you appeal a denied claim and win, a qualified independent contractor (second level of appeal) and administrative law judge (third level of appeal) could override the edit.
Example
A patient has bilateral cervical carotid stents placed. The following code is assigned:
- 37215-50: Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection
The Medicare Physician Fee Schedule (MPFS) lists a bilateral indicator of 1 for this code, which means it may be paid at 150% when bilateral services are billed.
As shown above, the MUE is 1. If you billed 37215 with two units of service or with modifiers -RT and -LT, the second code would be denied. However, because the MAI is 2, the MAC cannot override the edit unless a qualified independent contractor or administrative law judge approves the override. By billing on one line with modifier -50 and with one unit of service, the MUE is not exceeded.
MAI of 3: DOS edit based on clinical benchmarks
According to CMS, this is the most common per-day edit, which is based on clinical information (such as billing patterns or prescribing instructions) and data.
CMS states that "it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services." However, it continues:
If contractors have evidence (e.g., medical review) that units of service in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the contractor may bypass the MUE for an HCPCS code with an MAI of 3 during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher-level appeal.
Example
A patient has bilateral cerebral angiography from bilateral internal carotid artery catheterization, and the following code is reported with one unit of service:
- 36224-50: Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
There is an MPFS bilateral indicator of 1 for this code, allowing for bilateral payment, but the MUE of 1 would cause a denial of a second-line item if billed twice with the -RT and -LT modifiers, with modifier -59 or -76, or with units of two. Because the MAI is 3, the denial could be overturned on appeal with documentation that bilateral services were provided. By billing with modifier -50 and one unit of service, the MUE is not exceeded and assuming medical necessity and other requirements are met, the claim could be paid initially.
Managing the process
CMS advises that providers carefully assess any denials based on these edits and consider the denial to be an indication of incorrect reporting due to things such as clerical errors or errors in the interpretation or application of coding instructions.
Donna Richmond is a senior healthcare consultant in the radiology area of professional services with Panacea Healthcare Solutions.
