CEO SUMMARY: Medicare officials have granted a temporary respite on the troubling proposal to institute service restrictions per patient on some 80 pathology CPT codes and 1,100 clinical laboratory codes. These proposals are part of a new round of Medically Unbelievable Edits (MUEs). CMS has yet to answer questions about the rationale and motive behind these proposed edits.
UNDER PRESSURE from many fronts, the Centers for Medicare and Medicaid Services (CMS) extended deadlines for comment and implementation of a controversial and rather lengthy list of Medically Unbelievable Edits (MUEs).
For the pathology profession, the best advice may be former Yankee catcher and Mets coach Yogi Berra’s famous malaprop: “It ain’t over ’til it’s over!” That’s because, although CMS is extending the comment and implementation timetable for the contentious MUEs, it still plans to implement some form of new MUEs, stating that no implementation will occur before January 1, 2007.
It was THE DARK REPORT which first made public key aspects of the proposed MUE edits. A CMS contractor issued an extensive list of proposed restrictions of service to the American Medical Association (AMA) in mid-December 2005. This list included restrictions of service for approximately 80 pathology CPT codes and 1,100 clinical laboratory CPT codes. (See TDR, January 16, 2006.)
These MUE edits captured the full attention of anatomic pathologists when it was discovered that one proposed MUE targeted CPT 88305 (Level IV—Surgical Pathology, Gross and Microscopic Exam). The CMS contractor proposed to restrict the use of the 88305 CPT code to two units of service per patient per day.
Such a restriction on CPT 88305 would directly contradict accepted medical standards of care for a large number of diseases—many of which are life-threatening to affected patients. Restrictions to CPT 88305 would also have a devastating financial effect on anatomic pathology groups throughout the United States.
Apparent Lack Of Input
Equally disturbing to the pathology profession and the laboratory industry is the process used by CMS to develop the proposed MUEs and implement them. The subcontractor on the MUE project was a business unit of Empire Blue Cross Blue Shield in New York State. It apparently did its work in secret and isolated from expert sources. As it compiled a list of MUEs, it does not seem to have consulted with any medical specialty association.
Further, CMS was proceeding to implementation without using formal rule-making processes. It has also declined to make public the rationale and methodology that was used to create the list of proposed MUEs.
On both counts, critics are excoriating CMS. The College of American Pathologists has called upon CMS to: 1) utilize the formal rule-making process for proposed MUEs; 2) work closely with the provider communities to ensure that MUEs are aligned with accepted clinical standards of practice; and, 3) see that MUEs are only used for their intended purpose—to detect errors in claims submission.
Similar statements have been made to CMS by the Practicing Physicians Advisory Council (PPAC) and House Representative Nancy L. Johnson (R- Connecticut). On March 10, Johnson sent a letter to CMS Administrator Mark McClellan specifically calling attention to how pathology MUEs would negatively affect patient care.
The pathology profession and the laboratory industry must stay on high alert. Bad bureaucratic proposals tend to hang around year after year. Like the 20% lab test copay concept, restrictions on service for CPT 88305 are likely to threaten the profession for some time in the future.
Who Was Behind Controversial MUEs?
Upon learning that the proposed list of Medically Unbelievable Edits (MUEs) restricts units of service for CPT 88305 to two per patient per day, many pathologists want to know who originated this proposal.
After all, the proposed 88305 restriction directly contradicts established standards of clinical care and has the potential to put the lives of patients at risk. The irrationality of this decision is clear to both pathologists and the clinicians who refer cases.
Medicare’s list of proposed MUEs was developed under a subcontract granted to Empire Blue Shield Blue Cross in New York state. Knowledgeable sources tell THE DARK REPORT that the person in charge of this project at Empire was a medical director named Salvatore M. Moffa, M.D.
A cardiothoracic surgeon by training, Dr. Moffa left the employ of Empire Blue Cross Blue Shield during December 2005, around the time that the complete list of proposed MUEs for all medical specialties was delivered to the American Medical Association for distribution to specialty associations for their review and comment.
More than one source speculates that Moffa, who’s resume was posted on the Web in December and who was known to be seeking another job, may have simply put ones and twos in the column of “units of service per patient per day” for pathology and clinical laboratory CPT codes as an expedient way to complete his work.
Sadly, this is a believable scenario. If true, it is another example of how a healthcare bureaucracy can generate an irrational proposal, which then takes on a life of its own. More astonishingly, such irrational proposals often prove impossible to stop— despite the negative consequences that can be seen in advance of implementation.