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Don't miss these two increases to Medicare MUEs.

Want to get your 2025 off to a good start? Take a look at these recent important changes to Medicare coding edits, frequency edits, and Proprietary Laboratory Analyses (PLA) codes, and stay ahead of the path/lab coding curve.

Pay Attention to NCCI PTP Changes

Medicare added roughly 4,800 National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits effective Jan. 1, 2025. The goal of these NCCI edits is to prevent inappropriate payment of services that should not be reported together. Most of the added edits affect lab coding, particularly PLA codes.

Some of the new edits have a modifier indicator of 鈥�0,鈥� which means you should never report the two codes in the edit pair together. If you do report the two codes together, expect Medicare to deny the code in the column 2 position of the edit. Other edits have modifier indicator 鈥�1,鈥� which means you may override those edits using a modifier 鈥� but only in situations where documentation supports reporting the services for separate payment.

Examples: Here are a couple of 2025 edits involving 0417U (Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder-associated genetic variants):

One addition places 0417U in the column 2 position in an edit with column 1 code 0001U (Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported). This edit has modifier indicator 鈥�1,鈥� so you may override the edit with a modifier in those cases where the services are distinct.

In contrast, a 鈥�0鈥� modifier indicator lets you know you know that moving forward, you may never override an edit for 0417U and column 2 code 81460 (Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection). Both codes involve the whole mitochondrial genome.

Manual: The , effective Jan. 1, 2025, includes a few changes to Chapter 10, which applies to path/lab services. Pay particular attention to Section L.3, which adds +88185 (Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker)) in the section about duplicate testing. The manual states, 鈥淚f the abnormal cells in 2 or more specimens are morphologically similar and testing on one specimen by one method (CPT^庐 codes 88184, 88185, 88187, 88188, 88189, 88342, 88341, and 88344) establishes the diagnosis, the same or other method shall not be reported on the same or similar specimen.鈥�

Master MUEs to Avoid Claim Confusion

Another kind of NCCI edits, Medically Unlikely Edits (MUEs), also saw important changes beginning January 2025. To explain, 鈥渁n MUE is the maximum units of service (UOS) reported for a HCPCS/CPT^庐 code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service,鈥� according to . In other words, if you report units that exceed the MUE on the same date of service (DOS), you can expect problems for your claim.

Two lab codes saw increases to their MUEs. Code 82397 (Chemiluminescent assay) now has an MUE of 4 units per DOS, up from the 3 units NCCI assigned it in the last quarter of 2024. The MUE for 83516 (Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method) also changed, this time from 4 units per DOS to 6.

Medicare also added MUEs for many PLA codes. Most of them have an MUE of 1, but there are a couple of exceptions. The MUE is 3 units per DOS for 0455U (Infectious agents (sexually transmitted infection), Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, multiplex amplified probe technique, vaginal, endocervical, gynecological specimens, oropharyngeal swabs, rectal swabs, female or male urine, each pathogen reported as detected or not detected). And the MUE is 2 units per DOS for 0469U (Rare diseases (constitutional/heritable disorders), whole genome sequence analysis for chromosomal abnormalities, copy number variants, duplications/deletions, inversions, unbalanced translocations, regions of homozygosity (ROH), inheritance pattern that indicate uniparental disomy (UPD), and aneuploidy, fetal sample (amniotic fluid, chorionic villus sample, or products of conception), identification and categorization of genetic variants, diagnostic report of fetal results based on phenotype with maternal sample and paternal sample, if performed, as comparators and/or maternal cell contamination).

Apply January PLA Codes Now and Get an April Preview

January brought double news for as many changes became effective January 1, while CPT^庐 posted April changes for early review. For both January and April, oncology codes make up a large share of the changes.

In some cases, the changes reflect new proprietary, lab, or manufacturer names. For instance, 0288U was previously listed as DetermaRx鈩�, Oncocyte Corporation, but as of April 1, 2025, CPT^庐 will list it as RiskReveal鈩�, Razor Genomics.

In other cases, you get a completely new code, such as 0525U (Oncology, spheroid cell culture, 11-drug panel (carboplatin, docetaxel, doxorubicin, etoposide, gemcitabine, niraparib, olaparib, paclitaxel, rucaparib, topotecan, veliparib) ovarian, fallopian, or peritoneal response prediction for each drug) for 3D Predict鈩� Ovarian from Kiyatec^庐 Inc., which becomes effective Jan. 1, 2025.

Reminder: Each PLA code describes a unique lab test made by a specific manufacturer or performed by a specific lab. When a PLA code is available to report a service, you must use that PLA code rather than another code, such as one from the 80000 range.

Deborah Marsh, JD, MA, CPC, CHONC, Senior Development Editor, AAPC