Lab MUEs Reconsidered, CMS Changes Course

No clinical lab or anatomic pathology MUEs will be implemented until mid to late 2007

CEOSUMMARY: It may bear are moment of common sense. Last month, Medicare officials stated their intent to exclude clinical laboratory and anatomic pathology CPT codes from the “Phase One” implementation of Medically Unbelievable Edits (MUEs). It is a positive step, and comes in response to educational efforts by a consortium which included 60 associations and organizations from the laboratory community.

MEDICARE OFFICIALS are indicating their intent to exclude anatomic pathology and clinical laboratory CPT codes from the current list of Medically Unbelievable Edits (MUEs) proposed for implementation in January 2007.

“In recent meetings with individuals from the Centers for Medicare and Medicaid Services (CMS), we’ve been told that CMS has recognized that a different approach is needed for the clinical lab and anatomic pathology codes,” stated Alan Mertz, President of the American Clinical Laboratory Association (ACLA) in Washington, D.C. “This recognition has triggered a number of decisions which could help ensure that any proposed MUEs for laboratory and pathology services are appropriate and do not negatively affect patient care.”

As President of ACLA, Mertz was actively involved in a series of meetings with the CMS officials responsible for developing and implementing the MUE program. “During these meetings, the lab industry made a persuasive case that the existing MUE proposals, which involve 1,100 CPT codes, would be disruptive to both patient care and the healthcare system,” he said.

“We pointed out that the criteria used to propose these MUEs are unclear,” continued Mertz. “Also, there has never been a clear explanation or definition of either the overall process or the objective for implementing these edits.”

New Developments

Mertz says that, during a May 25 meeting with CMS officials, several positive developments occurred. “During this meeting, CMS stated that its thinking on the appropriate ways to develop the MUE program was evolving,” recalled Mertz. “CMS now indicates that implementation of MUEs will be much less widely-sweeping than what had been proposed. More specifically, the phase-in scheduled for January 2007 will focus primarily on anatomic anomalies and obvious typographical errors.”

The big development was the exclusion of clinical laboratory and anatomic CPT codes from the scheduled January 2007 implementation. “Further, the laboratory community does not need to provide specific comments to the current MUE proposals by June 19,” explained Metz. “CMS says it will establish a separate process and time-line for defining which clinical laboratory and pathology codes should be subject to MUEs. It will also involve the pathology and clinical laboratory community in defining the criteria to be used in developing such MUEs.”

Need to Remain Cautious

Although these developments are welcome across the lab industry, Mertz is quick to caution that, as of this date, CMS has yet to issue written guidance that confirms these shifts in the existing timetable for the proposed MUEs. “Much of the reasoning and organization behind the original MUE proposals remains unknown,” said Mertz. “The laboratory community must continue to work together. CMS needs input for it to evolve the MUE program in a fashion that accomplishes clear and objective goals while not compromising patient care.”

Mertz’s recommendation reflects the reality of working with the Medicare program. Not only does the bureaucracy work in ways unfathomable to the outside, but politics and Congressional mandates play a role in shaping how CMS develops and implements new policies.

During the next few months, it is expected that CMS will publish detailed guidance on how it intends to implement “Phase One” MUEs that are scheduled to take effect in January 2007. Once this guidance is published, the laboratory industry will need to maintain a common effort. The goal is to provide the input needed so that CMS can make fair, objective, and patient-friendly policies.

First MUE Proposals Were Disruptive to Labs

WHEN THE FIRST LIST OF PROPOSED Medically Unbelievable Edits (MUEs)became known in December 2005, it was a most unpleasant surprise to the laboratory industry.

The list proposed service restrictions for about 80 anatomic pathology CPT codes and 1,100 clinical laboratory CPT codes. The most disruptive proposal was to limit CPT 88305 (Level IV—Surgical Pathology, Gross and Microscopic Exam) to two units of service per patient per day. If implemented, such a limitation would have severely compromised patient care and eroded the core finances of most community hospital-based pathology group practices. (See TDR, January 16, 2006.)

“In meetings between CMS (Centers for Medicare and Medicaid Services) and the laboratory community, we’ve pointed out several things,” observed Alan Mertz, President of the American Clinical Laboratory Association (ACLA). “First, laboratory medicine CPT codes are far more numerous than those of other medical specialties, numbering more than 1,100. Second, these codes generally do not relate to a specific site in the body, making anatomic considerations mute.

“Third, while it is physically possible to perform only one appendectomy on a person,” said Mertz, “for all practical purposes, it is difficult to define the number of surgical pathologies, molecular probes, and chemistry analytes for which, beyond that number, it would be considered ‘unbelievable.’

“For these reasons, the process used to develop MUEs for clinical laboratory and anatomic pathology CPT codes must reflect the unique nature of laboratory medicine,” noted Mertz. “That will require effective collaboration between CMS and the laboratory community.”

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