KMAP BULLETIN: CMS MUE and PTP Edit Corrections

Date: 04/05/18

KMAP GENERAL BULLETIN 18083

The Centers for Medicare & Medicaid Services (CMS) identified an error in the April 1, 2018 Medicaid Outpatient Hospital (OPH) Medical Unlikely Edits (MUEs) file. The OPH MUE indicator for CPT® code 80055 was inadvertently changed from its current value of 1 to a value of 0 effective April 1, 2018. The indicator was corrected in the Kansas Medical Assistance Program (KMAP) system prior to April 1, 2018, to avoid any inappropriate denials. CMS will show the correct value of 1 in the July 1, 2018 OPH MUE file.

CMS also identified an error in the April 1, 2018 Medicaid Paperwork Reduction Act (PRA) and OPH Procedure-to- Procedure (PTP) edits that pair CPT code 81211 as the column 1 code with code 81213 as the column 2 code. This should have a Correct Coding Modifier Indicator (CCMI) of 1 (which allowed the edit to be bypassed if an appropriate

PTP-associated modifier was appended to one of the codes). The CCMI was inadvertently changed to 0 in the January 2018 Medicaid NCCI edit files and carried through to the April 2018 edit files. The CCMI will be changed from 0 to 1 and any affected claims will be reprocessed. CMS will show the correct CCMI in the July 1, 2018 Medicaid PTP and OPH PTP edit files retroactive to January 1, 2018.

Note: The implementation of State policy by the KanCare managed care organizations (MCOs) may vary. The KanCare Open Claims Resolution Log on the Kansas Medical Assistance Program (KMAP) Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates, once the policy is implemented.

Note: Refer to the CPT® codebook for complete descriptions.

CPT codes, descriptors, and other data only are copyright 2018 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply. Information is available on the American Medical Association website.