Published on August 28, 2007
PPAC Makes CAP Recommendation on MUEs
Washington, D.C.—A recommendation to make Medically Unlikely Edits (MUE) publicly available was endorsed by the Practicing Physicians Advisory Council (PPAC) and presented to the Centers for Medicare and Medicaid Services (CMS) during Monday’s PPAC meeting. The recommendation, presented by the College of American Pathologists (CAP) in earlier communications to CMS, was reiterated in CAP testimony to the PPAC presented by Jonathan Myles, MD and FCAP.
“There has been a lot of conflicting information from CMS regarding the intent to make MUEs publicly available,” Dr. Myles said. “We are pleased PPAC shares our concerns and are hopeful that CMS will respond favorably.
“On the one hand, CMS has previously stated that MUEs will not be published so that providers cannot game the system,” Dr. Myles said. “On the other hand, CMS has stated that a modifier –59 can be used for CPT codes that exceed the MUE limit. Without knowing the MUE, how could a physician know to use a modifier?”
The CAP has expressed several concerns since MUEs were proposed by CMS nearly two years ago. MUEs are being developed to help the agency reduce fraud and abuse by testing claims against a units-of-service limitation or MUE intended to catch typographical errors and unlikely cases submitted to Medicare for payment. CMS plans to have MUEs in place for the majority of pathology services as well as CPT codes for all medical specialties that could potentially result in the denial of valid claims.
The first four releases of MUEs have largely focused on anatomic edits, but phase five will be developed based on clinical judgment, Dr. Myles explained. “Determining medical necessity based on clinical judgment represents a great degree of complexity and it is not clear that the current review process adequately provides for an open and transparent discussion regarding the maximum units of service that are medically necessary for a given code. Relying on clinical judgment potentially encroaches into the realm of payment policy rather than pure enforcement of existing rules. Yet, MUEs are currently being implemented without the safeguards of the rulemaking process.”
“Although the CAP supports the agency’s effort to reduce fraud and abuse of the Medicare system, it is time to form a working group that would help establish a more transparent process that would include formal participation from the laboratory and pathology communities,” Dr. Myles concluded.
CMS has agreed to meet with CAP officials to discuss the formation of a working group that would include all stakeholders including CMS officials, the CMS contractor for MUEs and various others from the laboratory and pathology community.
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.