Medicare Publishes Billing Edits to Reduce Payment Errors

CMS Message - 200810-08

The Centers for Medicare & Medicaid Services (CMS) recently announced that, beginning October 1, 2008, it will publish most of the edits utilized in its Medically Unlikely Edit (MUE) program to improve the accuracy of claims payments.
"It is always our aim to ensure that CMS pays for appropriate services, at the same time protecting the Medicare Trust funds and the American taxpayer," said CMS Acting Administrator Kerry Weems. "This program is going to help us dramatically reduce costly payment errors."
CMS established the MUE program to reduce payment errors for Medicare Part B claims. Claims processing contractors utilize these edits to assure that providers and suppliers do not report excessive services. The edits are applied during the electronic processing of all claims. These edits check the number of times a service is reported by a provider or supplier for the same patient on the same date of service. Providers and suppliers report services on claims using HCPCS/CPT codes along with the number of times (i.e., units of service) that the service is provided.
Prior studies, including one by the U.S Department of Health and Human Services' Office of the Inspector General in May 2006, identified significant Medicare overpayments because provider or supplier claims sometimes report services with too many units of service. These errors may be caused by numerous factors, including clerical errors and coding errors.
CMS first implemented the MUE program January 1, 2007, with edits for about 2,600 HCPCS/CPT codes. There have been quarterly updates adding additional codes. The October 1, 2008, version of MUE will contain edits for about 9,700 HCPCS/CPT codes that have been assigned unit values for MUEs. MUEs are cumulative for each quarter. However, CMS will not publish all MUEs on October 1, 2008. CMS has not yet determined if there have been any savings in the MUE program since it was implemented.
The edits were developed by CMS with the cooperation and participation of national health care organizations representing physicians, hospitals, non-physician practitioners, laboratories, and durable medical equipment suppliers. CMS also utilized claims data in its analysis of MUE.
The edits can be found on the CMS Website at http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage.
At the start of each calendar quarter, CMS will publish most MUEs active for that quarter. Although the October 1, 2008, publication will contain most MUEs, additional ones will be published on January 1, 2009. CMS is not able to publish all active MUEs because some are primarily designed to detect and deter questionable payments rather than billing errors. Publishing those MUEs would diminish their effectiveness

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MEDICARE

Medicare is a federal government health insurance program which pays for certain healthcare services and originated from a federal law, title XVIII of the Social Security Act.
Medicare is health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, too, including those who have disabilities and those who have permanent kidney failure. The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long term care

Medicare is managed by Centers for Medicare and Medicaid Services (CMS), which covers nearly 40 million Americans and provides coverage for:
 People age 65 or older,
 Some people under age 65 with disabilities,
People with End-Stage Renal Disease (ESRD),
which is permanent kidney failure requiring dialysis
or a kidney transplant.

PART A
Hospital insurance plan financed mostly through taxes on employers and employees. Persons who qualify for Medicare receive Part A automatically. A beneficiary or beneficiary’s spouse must have paid Social Security Taxes or premiums for at least 10 years/40 quarters.

PART B
Supplementary medical insurance that pays for physician services and other services not covered under Part A. persons who qualify for Medicare do not automatically receive Part B. These individuals must purchase Part B.

Medicare Part A:
Part A of the Medicare Program is for inpatient services and hospitals submit Medicare claims to Part A intermediary. Part A benefits include: Hospital stays, Skilled nursing facility, Home health care, Hospice care, or care in a psychiatric hospital.
Medicare Part B:
Part B of the Medicare Program is for professional/physician services. This coverage helps pay for medical and surgical services by physicians as well as certain other health benefits such as ambulance transportation, durable medical equipment, outpatient hospital services, and independent laboratory services.