During a recent national call of the COA Administrators’ Network (CAN), the issue of Medicare payment problems associated with CPT code 96367 was raised. Many practice administrators expressed concern over the rejection of submitted claims that contained more than three (3) sequentially infused drugs during one visit/occurrence. It was then learned that the Centers for Medicare and Medicaid Services (CMS) had put in place a Medically Unlikely Edit (MUE) effective January 1, 2012, limiting sequential infusions to a maximum of three substances.
COA is pleased to report that based on the MUE problem raised on the CAN call, and subsequent input from several practices, the MUE is being changed. We have had numerous communications with Dr. Niles Rosen at the National Correct Coding Initiative (NCCI), which administers the MUEs for CMS. Dr. Rosen sent us the following:
“We have had further discussion with CMS which owns MUE and determines its contents. We will make a temporary change in the MUE value for this code in the April 1, 2012 version. The change will be retroactive to January 1, 2012. The new value, like the previous value is a confidential, unpublished value but is high enough to allow for the three examples that you provided. If your members choose to hold their claims until April 1, 2012, their claims will be adjudicated against the new value. Alternatively, until April 1, 2012, your members reporting more than 3 UOS (units of service) of medically reasonable and necessary sequential infusions of new drugs/substances can use the method that I previously described reporting the code on two lines of a claim appending modifier 59 to the code on one line and dividing the total UOS between the two lines.”
So, you have 2 courses of action: Hold your claims until April 1, 2012 or follow the work-around provided by Dr. Rosen as follows:
CMS requires that claims processing contractors adjudicating claims deny an entire claim line if the provider reports units of service that exceed the MUE value for the code on the claim line. A provider may appeal the claim line denial to his local claims processing contractor. Alternatively, if the provider plans to report medically reasonable and necessary UOS in excess of the MUE value, the provider may report the code on two claim lines using modifier 59 appended to the code on one claim line and divide the UOS between the two claim lines. The MUE value for this code is adjudicated against each claim line separately. Thus, the provider could report up to six UOS for this code on two claim lines without hitting the MUE.
If you have any questions about this please contact Mary Kruczynski, Director of Policy Analysis at COA at maryk@COAcancer.org.
This is just one example of the power of sharing information among administrators and working together. If it had not been for the COA Administrators’ Network members, who truly are hands-on in the billing and reimbursement arena for oncology, the concern over the impropriety of this MUE would not have been raised at all. We have requested that COA be included in the MUE review process to correct mistakes before they are made, as in this case. In fact, NCCI and CMS have asked to meet with us to discuss these issues, which we will be doing.
If you are interested in being part of the CAN communications network, contact Jen Foth, Executive Assistant, at jfoth@COAcancer.org.
Background as an FYI
On January 27, 2012, COA wrote a formal request letter to Dr. Niles Rosen at NCCI in connection with the MUE on CPT code 96367, which was raised during a call of the COA Administrators’ Network. In its research, COA failed to locate any discussion or objections raised by those who represent the specialty of oncology to either the NCCI or CMS. And indeed, a response from Dr. Niles to our transmission of January 27confirmed this, “As of this date CMS has not received any other complaints about this MUE value. Prior to implementation it was released for a sixty-day review and comment period to over 100 national healthcare organizations including the American Society of Clinical Oncology and American Hospital Association. No organization objected to the MUE value.”
Please note that in COA’s letter to the National Correct Coding Initiative, we also provided several of the examples that CAN members forwarded to us that allowed Dr. Niles to discuss with CMS, which owns MUE and determines its contents. Dr. Niles also assured us that they were VERY concerned about this issue.
Dr. Rosen first responded with the work-around solution. Then, after further communications from COA and discussions with CMS, Dr. Rosen informed us of the decision related above.