January 24, 2018

CMS Issues a Revision for MUEs and Bilateral Surgical Procedures

The Centers for Medicare & Medicaid Services (CMS) announced coding revisions to Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures with details and examples for correct coding in the Jan. 17, 2018, issue of Medicare Learning Network (MLN) Matters®.

The revision of article SE1422, originally released on June 30, 2014, is intended for all Medicare fee-for-service (FFS) physicians, non-physician practitioners, providers and other health care professionals who bill Medicare Administrative Contractors (MACs) using the Medicare Physician Fee Schedule (MPFS) for bilateral surgical procedures for beneficiaries.

Coding claims for surgical procedures performed bilaterally depends on:

1 - The Healthcare Common Procedure Coding System (HCPCS) code descriptor

2 - The “bilateral indicator” assigned to the HCPCS code (that is, whether special payment rules apply)

3 - The nature of the service

The National Correct Coding Initiative (NCCI) manual specifies that modifier 50 is used to report bilateral surgical procedures as a single unit of service. The NCCI manual warns that MUE edits based on established CMS policies may limit units of service and are predicated on the assumption that claims are coded in accordance with these Medicare instructions. Consequently, many bilateral procedures have an MUE value of 1.

Bilateral indicators only apply to MPFS and not to other Medicare payment systems.

For detailed information, see the Jan. 17, 2018, issue of MLN.