Dear ACRO Member:
A Medically Unlikely Edit (MUE) is a CPT unit of service
edit for physician services to a single beneficiary on one
date of service. Generally there is limit on a certain number
of units of a CPT Code that would be reported for a patient on
a single day. The medically unlikely edits were developed
based on clinical judgment and these edits were reviewed by
Insurance Medical Directors. Medically unlikely edits are used
to potentially screen out too many units of service done a
single day.
How does this affect Radiation Oncology? For irregular
fields or large IMRT fields more than 10 dose calculations
(77300) or more than 10 multi-leaf configurations (77334) may
be needed for a patient treatment. Generally the treatment
plan is produced on a single day, and all calculations and
multi-leaf configurations would be performed on a single day.
Currently, there is an MUE that rejects payment of more than
10 units of 77300 or 77334 on a single day. Thus when this
number exceeds the amount allowed by the MUE, the entire
quantity is rejected for payment. This leaves the physician in
the situation of not being paid for a single dose calculation
or multi-leaf configuration.
Nearly 20 percent of processed Medicare claims are denied;
however, only 5 percent of denied Medicare claims are appealed
(1). Physicians are successful in appealing payments denied in
more than 60 percent of cases. The first level of appeal is a
fair hearing, and is usually conducted by sending additional
information with a letter as to why you think that your claim
should be processed as submitted. This can either occur with
or without a telephone meeting. In my experience, fair
hearings have yielded payment up to 10 dose calculations or 10
multi-leaf configurations, but not more than 10.
The next level of appeal is an administrative law hearing.
This is formal and represents a hearing and a trial as to
whether you can or cannot be paid. The judge in this situation
doesn't appear to be interested in what the patient needed but
rather whether the law does or does not allow additional
payment.
In a recent administrative law hearing held on these two
issues, specifically, whether additional multi-leaf charges
beyond 10 could be charged and paid for by Medicare, and
whether additional dose calculations beyond 10 could be
performed and paid for by Medicare, our cancer center recently
prevailed. The ruling states that we produced a number of
office notes detailing why these extra units were necessary in
each case, therefore a good cause is established for the
necessary and fair resolution of this matter with payment in
our favor. There is no law prohibiting additional payments.
Thus, to get paid for the work that you perform on behalf of
your patients, persist.
In the event that radiation oncologists feel that MUE
policies should be modified (as I do), the National Correct
Coding Initiative requests your input at National Correct
Coding Initiative Correct Coding Solutions LLC, PO Box 907,
Carmel, Indiana 46082-0907 or Fax them to 317-571-1745.
Thank you,
Paul J Schilling, MD, FACRO
Community Cancer Center of
North Florida, Gainesville Florida
(1) Economics of Radiation Oncology, Principles and
Practice of Radiation Oncology
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