Do these Medicare changes affect your practice? Read on to prevent denied claims in 2015.
1. MUE modifications (implementation date: Jan. 5, 2015): A Medically Unlikely Edit (MUE) value is the maximum units of service most physicians would reportfor
a procedure code for the vast majority of patients receiving the service for the same patient on the same date of service. In 2013, CMS modified the MUE program so that some MUE values would be date-of-service edits rather than claim line edits. At that time, CMS introduced a new data field to the MUE edit table termed "MUE adjudication indicator" (MAI). CMS is currently assigning an MAI to each code:
- MUEs for codes with an MAI of 1 will continue to be adjudicated as a claim line edit.
- MUEs for codes with an MAI of 2 are absolute date-of-service edits. These are "per day edits based on policy."
- MUEs for codes with an MAI of 3 are date-of-service edits. These are "per day edits based on clinical benchmarks."
For more information, including general processing instructions, see MLN Matters No. 8853 (PDF).
2. NPI reporting on antimarkup and reference laboratory claims (implementation date: claims received on or after Jan. 1, 2015): Changes to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) will allow Notivas Solutions and other Medicare administrative contractors (MACs) the ability to verify all physician and supplier National Provider Identifiers (NPIs), regardless of the MAC jurisdiction in which they are enrolled.
- Beginning with claims dated Jan. 1, 2015, physicians billing antimarkup and reference laboratory claims must report the NPI of the physician or supplier who actually performed the service in Item 32a (or electronic equivalent) of the CMS-1500 claim form.
- This new requirement applies to all claims, including claims for services where the performing physician/supplier is out of the processing MAC's jurisdiction.
For more information, see MLN Matters No. 8806 (PDF).
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Revised Nov. 4, 2014
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Last Updated On
May 13, 2016