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Double Check: Confusion Over CCI Edits and MUEs Leading to Short Reimbursements for Outpatient/ASC

August 8, 2017 by Catherine Montgomery

DaisyBill has been paying almost obsessive attention to the Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule. As we should; we worked hard to integrate it into our OMFS Calculator[a][b][c].

So when the California Division of Workers’ Compensation (DWC) recently adopted an order changing that fee schedule, we scrutinized the changes— and asked a few important questions.

Specifically, we reached out to the Department of Industrial Relations (DIR) on the matters of Correct Coding Initiative (CCI) edits and Medically Unlikely Edits (MUEs). What we discovered is easy to miss, but has important implications for compliant bill review.

A DIR employee confirmed that the department “ha[s] not adopted CCI Edits for Outpatient / ASC fee schedule facility billing.” That’s right: CCI edits and MUE’s do not affect the Outpatient/ASC fee schedule. 

Unfortunately, some bill reviewers still assume otherwise.

Several bill review companies have been citing CCI edits or MUEs to reduce payments for outpatient or ASC bills. It’s an understandable mistake – if some code combinations  violate CCI rules for the physician fee schedule, it’s not crazy to think the same would hold true for outpatients.

Not crazy, but not accurate, either. While it’s an easy error to make, it’s one that costs providers money. It’s also non-compliant, and any provider who’s been paid improperly should appeal for full reimbursement.  

We’ve encountered this issue with Genex, which handles bill review for the County of San Diego, among other employers. If you notice this problem with any of your outpatient or ASC bills, please get in touch.

Our Work Comp Wizard software, which is the foundational tool of all DaisyBill products, automatically calculates reimbursements for the Outpatient / ASC Fee Schedule – along with six other fee schedules – using the most recent Medicare files and DWC reimbursement formulas. Work Comp Wizard subscriptions are just $49 per month, come with a free three-day trial, and are cancellable at any time. You can learn more here.

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FAQ:

How do the recent Correct Coding Initiative (CCI) edits and Medically Unlikely Edits (MUE) affect the Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule?

They don’t! These changes, while applicable to the Physician Fee Schedule, have no bearing on the Outpatient/ASC schedule.

Have payments to Outpatient Departments or ASCs been reduced based on CCI edits and MUE?

Unfortunately, yes. This is a mistake on the part of bill reviewers. For example, Genex has committed this error for some of its clients, including the county of San Diego.

What if an Outpatient Department or ASC has received a reduced payment based on CCI edits or MUE?

This is non-compliant, and providers should appeal for full reimbursement.

Original Follows Below

DWC: CCI Edits and MUEs Not Applicable For Outpatient / ASC Fee Schedule

August 8, 2017 by Catherine Montgomery

The DaisyBill development team has been working around the clock to integrate the Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule into our OMFS Calculator. So when the California Division of Workers’ Compensation (DWC) recently adopted an order changing that fee schedule to conform to Medicare, we were ready with our questions. Specifically, we reached to the Department of Industrial Relations on the matter of Correct Coding Initiative (CCI) edits and Medically Unlikely Edits (MUEs) for this fee schedule.

A DIR employee confirmed that the DIR “ha[s] not adopted CCI Edits for Outpatient / ASC fee schedule facility billing.” We repeat: CCI edits and MUEs do not factor into the Outpatient / ASC fee schedule.

That hasn’t stopped several bill review companies from citing CCI edits or MUEs to reduce payments for outpatient or ASC bills. It’s a simple enough mistake – if a combination of codes violates CCI rules for the physician fee schedule, applying those edits to other fee schedules may simply be force of habit. But it’s technically non-compliant behavior and full reimbursement should be pursued by the provider via second bill review.

We’ve encountered this issue with Genex, which handles bill review for the County of San Diego, among other employers. If you notice this problem with any of your outpatient or ASC bills, please get in touch.

Our Work Comp Wizard software, which is the foundational tool of all DaisyBill products, automatically calculates reimbursements for the Outpatient / ASC Fee Schedule – along with six other fee schedules – using the most recent Medicare files and DWC reimbursement formulas. Work Comp Wizard subscriptions are just $49 per month, come with a free three-day trial, and are cancellable at any time. You can learn more on our website.

[a]Insert link if we show it on the website in time.

[b]To...the WCW?

[c]if daisybill.com shows the ASC calculator, As of yesterday, it shows that it supports several fee schedule, but not the ASC.

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