Q&A: Responding to edits on HCPCS J codes

Q: We are seeing medically unlikely edits (MUE) on HCPCS J codes. How do we handle these?

A: First, you need to double-check: are you correctly calculating the units based on what was ordered and administered to the patient per the HCPCS unit definition? Second, you have to look at whether the code is packaged or not. If it is being billed correctly with the correct number of units, and the units exceed the MUE and the drug itself is packaged, you do have an alternative to bill that under revenue code 0250 (general classification) and get all your charges in the door. That would recognize the total cost of the claim.

If you have a physician document that it’s a chemotherapy drug or a monoclonal antibody, and you have a physician order it who specializes in oncology, rheumatology, or the specialty specific to the drug, as well documentation from your pharmacist that supports why that’s a wrong MUE, there’s a second avenue. Submit that information to the National Correct Coding Initiative contractor and Medicare and explain why these experts disagree with the MUE. That will carry some weight with CMS.

If it is a separately paid drug, the only way to get that recognized is to appeal, but otherwise, check and be sure that your units are calculating correctly and your documentation supports it, and then figure out your next step from there.

Editor’s note: Denise Williams, RN, COC, senior vice president of revenue integrity services at Revant Solutions, and Valerie A. Rinkle, MPA, lead regulatory specialist and instructor for HCPro's Revenue Integrity and Chargemaster Boot Camp, answered this question on the webinar “NCCIs and MUEs: Solving Claims Edits.” 

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