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Published on July 27, 2006
Good News on MUEs: Pathology Excluded from January Implementation
Washington, D.C.—The College of American Pathologists (CAP) today received good news from a Centers for Medicare and Medicaid Services (CMS) contractor announcing that the first phase of units of service edits are based on anatomic criteria, which results in the exclusion of pathology services from the January 2007 implementation of Medically Unlikely Edits (MUEs).
A letter from the CMS contractor for the National Correct Coding Initiative (NCCI) stated MUEs will be implemented in quarterly phases and that CMS had changed the name of the MUEs from Medically “Unbelievable” Edits to Medically “Unlikely” Edits. Included with the letter was the list of MUEs released for public comment. The College notes that although there are several laboratory codes (G codes) for cytopathology and cancer screening on the list, absent from the list are the previously proposed unit of service edits for all pathology and laboratory services.
“We have been working very closely with CMS regarding MUEs and are pleased to see that some of our concerns have been addressed,” said Thomas M. Sodeman, MD, FCAP, and president of the CAP. “We will continue to address other outstanding issues to ensure the implementation of MUEs does not have a negative impact on the pathology community.”
The original MUE proposal released for comment last January has caused serious concern within the pathology community because it would impose units of service limitations on each and every physician service under Medicare and result in automatic denials of all claimed units in excess of the criteria units of the service ceiling. On May 22, a CMS official announced a change in direction in the current MUE proposal before the Practicing Physicians Advisory Council (PPAC), stating that an additional set of edits will focus on typographical errors is expected to be released later this summer for public comment. CMS has further stated that they are seriously considering the use of modifiers and the development of an appeals process.
A June 19 CAP letter to NCCI reiterated its concerns about the proposal with respect to the 80000 series of codes, the Laboratory and Pathology section, about the lack of definition of “medically unbelievable” and the absence of any guidance as to the methodology or underlying principles used to develop the current proposal that would allow the CAP to help structure a more meaningful response.
A College-led coalition of 60 pathology and laboratory groups has consistently stated to CMS that while they would like to provide useful comments on the proposed MUEs, clarification is needed on a number of important issues, including the rationale and methodology for current edits and the policy for overriding modifier use and appeal. In addition, the coalition has suggested that not all pathology and laboratory services may be candidates for MUE’s.
The College of American Pathologists (CAP) is a medical society serving about 16,000 physician members and the laboratory community throughout the world. It is the world’s largest association composed exclusively of pathologists and is widely considered the leader in laboratory quality assurance. The CAP is an advocate for high quality and cost-effective patient care.
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