The Centers for Medicare & Medicaid Services (CMS) recently released MLN Article SE1422 to remind providers about the Medicare directive of certain bilateral surgical procedures having the requirement of being filed with a 50 modifier and one unit of service (UOS). Claims that may have been paid in the past could now be rendered un-payable due to the MUE changes.

Although there are several ways that claims for bilateral procedures could be coded, each method is correct only for specific situations. For Medicare claims, if the term bilateral is not included in the current procedural terminology (CPT®) code descriptor, the Medicare Claims Processing and the National Correct Coding Initiative (NCCI) manuals state that these procedures should be reported on a single line item, with one UOS and the 50 modifier. 

The Office of Inspector General (OIG) submitted a recommendation to CMS to examine claims data relating to MUE levels, whereby CMS identified a pattern of erroneous billing using multiple line items to bypass the MUE's. This not only leads to overcharging in the Medicare program but also to beneficiaries as well.

As of July 1, 2014, the published per day edits are identified on the CMS NCCI website by their MUE adjudication Indicator (MAI) value of two or three. MAI 2 will indicate an edit for which the MUE is based on policies which include instructions that are inherent in the code descriptor or any applicable anatomy. A MAI 3 will be the most common per day edit and will be based on specific clinical information. Please review the entire MLN article for direct and clear instruction on these edits and their meanings or visit the CMS MUE site.1

1MLN Matters® Number SE1422, CMS (June 30, 2014).

Category: