|
Medically Unlikely Edits (MUE)
Effective January 1, 2007 CMS initiated edits referred to as MUEs. A MUE is defined as an edit that lists claim lines for the same beneficiary, HCPCS code and date of service against the MUE criteria, which contains the number of units of service. When the claim line item units of service is in excess of the MUE criteria, the claim will be returned to the provider (RTP) for consideration.
CMS said they have set the units of service for each MUE high enough to allow for medically reasonable daily frequencies of each service. The MUEs effective January 1st were based on anatomical consideration that includes approximately 2,800 codes.
These edits were established in order to lower the Medicare fee-for-service paid claims error rate.
New Edit 76
Another new edit 76 was implemented in the January 2007 OPPS Outpatient Code Editor specifications (OCE), Version 8.0. Edit 76 is initiated when trauma response critical care code (G0390) is listed on the claim without revenue code 068x and CPT code 99291 (critical care) for the same date of service. If these conditions are not met the trauma response critical care code will be rejected.
Effective January 1st you can now report new HCPCS code G0390 when appropriate. The trauma response team activation associated with critical care code (G0390) is only to be used by trauma center/hospitals as licensed or designated by the state or local government authority authorized to do so or as verified by the American College of Surgeons and involves trauma activation. Only claims on patients for whom there has been pre-hospital notification or have been delivered by inter-hospital transfers and have been given the appropriate team response can be billed with the trauma activation code and accompanying charges. Patients who are “drive by” or arrive without notification cannot be charged for the trauma activation codes. Providers should report 1 unit of G0390 using revenue code 068x when trauma is activated by a certified trauma center. HCPCS code G0390 should be reported in addition to CPT 99291. In these cases there are two separate APC payments made to the facility: APC 0617 paying $405.04 for critical care services (CPT code 99291) and APC 0618 paying $494.54 for the trauma response team (HCPCS code G0390).
Currently there are 76 different edits in the OCE, ten of which are inactive.
|
