August 17, 2007 - ASM Comments on Phase V Implementation of Medically Unlikely Edits (MUEs)

Niles R. Rosen, M.D.
Medical Director
National Correct Coding Initiative
Correct Coding Solutions LLC
P.O. Box 907
Carmel, IN 46082-0907
 
Dear Dr. Rosen:

The American Society for Microbiology (ASM) appreciates the opportunity to review and comment on the proposed National Correct Coding Initiative Medically Unlikely Edits (MUEs), Phase V. The ASM is the largest, single life sciences Society dedicated to the advancement of the microbiological sciences and their application for the common good. The Society represents approximately 42,000 microbiologists, including scientists and science administrators working in a variety of areas, including biomedical, environmental, and clinical microbiology.

Many of ASM’s members have primary involvement in clinical laboratory medicine including individuals directing clinical microbiology or immunology laboratories, individuals licensed or accredited to perform such testing, industry representatives marketing products for use, and researchers involved in developing and evaluating the performance of new technologies. Thus, our Society has a significant interest in correct coding for laboratory testing to ensure reasonable reimbursement for medically necessary laboratory testing for Medicare beneficiaries.

The ASM appreciates the need to perform systematic post claim reviews to identify aberrant utilization patterns including the establishment of MUEs to detect over utilization or utilization that is incompatible with anatomic considerations, CPT code descriptors or coding instructions, existing CMS policies, the nature of an analyte, the nature of a procedure or service, or the nature of equipment. In addition, we appreciate that medical standards of care and medical judgment must be considered in developing MUEs. For the Phase V MUEs, we have concerns with several CPT codes for direct specimen testing for infectious diseases for which analyte specific codes have not yet been developed by the AMA. Assays for which analyte specific codes are not available must necessarily be coded for using a “not otherwise specified code,” and we are concerned that the MUEs proposed are overally restrictive in a rapidly emerging technical climate as well as in a climate of rapidly emerging infectious diseases. As requested, our specific concerns, recommendations and supporting information are attached in a separate document. As we move forward in the MUE process, these concerns will be similarly stated for other “NOS” CPT codes which are appropriately used more than one time for a single date of service due to analyte complexity not accounted for in the current CPT coding structure.

The ASM appreciates the opportunity to review the Phase V proposed MUE edits and make recommendations prior to the January 1, 2008 implementation date. We support the goal of the Centers for Medicare & Medicaid Services and its contractors to provide medically necessary and clinically appropriate laboratory testing to Medicare Part B beneficiaries through the process of correct coding and judicious utilization. However, we are also dedicated to ensuring that claims review programs not be established which could inappropriately restrict the ability of ordering providers to obtain medically necessary diagnostic information, the ability of beneficiaries to receive the benefit of such laboratory testing, or the ability of the laboratory to receive appropriate reimbursement for services performed.

Please let us know if we can provide any additional information to further assist you or to clarify our concerns and recommendations.

Sincerely,

Vickie S. Baselski, Ph.D., Chair
Committee on Professional Affairs
Public and Scientific Affairs Board

TPL_asm2013_SEARCH