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  Letter Responding to an
  MUE Proposal by the CMS

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January 8, 2007

Niles Rosen, MD
National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, Indiana 46082-0907

Dear Dr. Rosen,

The College of American Pathologists is responding to an MUE proposal by CMS that was issued to medical societies on November 6, 2006 by the AMA. These MUEs are proposed for implementation in April 2007.

We would first like to thank CMS for responding to the concerns of the medical community by revising the content and process for what are now being termed Medically Unlikely Edits. Following the logic of medically unlikely as set forth, we believe that MUEs should be set at a level of unlikelihood such that only exceptional cases would fail to meet the MUE criterion for the service, and that these cases would therefore properly be adjudicated through a process of individual appeal, obviating the use of override modifiers, as agency representatives have indicated.

With regard to your proposed edits, we agree with your general approach for setting some MUEs based on the nature of an analyte, which are determined by one of three considerations (i.e. timing or the physiology, pathophysiology, or clinical application of the test). However, we do have concerns about some specific edits for other codes not covered by the above criteria. Our concerns are specified in the attached spreadsheet (Excel, 26 K). We would also like to comment on your proposal to crosswalk MUEs for new codes based on a similar code that may have been deleted in the previous year. We do not believe that there is always a suitable replacement of one MUE for another, despite some similarity in the codes. We believe such events should be evaluated on a case-by-case basis.

We thank you for the opportunity to respond to this latest set of MUEs. If you have any further questions regarding our response, please contact Janemarie Mulvey at the College of American Pathologists at (202) 354-7110.

Sincerely,

W. Stephen Black-Schaffer, MD, FCA
CAP Representative to the Correct Coding Initiative

Cc:
John D. Stewart, CMS/OFM
Lisa Zone, CMS COTR
Valeria Allen, CMS COTR
Michael D. Maves, MD, Executive Vice-President, AMA
Karen O’Hara, AMA
Linda Dietz, Correct Coding Solutions