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Medically Unlikely Edits

February 5th, 2013

In ongoing efforts to stop inappropriate payments, the Centers for Medicare and Medicaid Services has implemented a system for detecting and denying unlikely Medicare claims on a pre-payment basis. This system consisting of a series of coding edits termed Medically Unlikely Edits (MUEs) took effect January 1, 2007. It specifically works to reduce the paid claims error rate for Medicare Part B claims.

Developed by CMS contractor Correct Coding Solutions, LLC and some of the same folks who developed the initial NCCI edits under AdminaStar Federal, the MUEs function to facilitate auto-adjudication. While the NCCI edits compare codes on different lines of the claim form, the MUEs look at the units of service (UOS) reported per code. The edits place maximums on the number of units of service per code that can be reported by a provider for the same beneficiary on the same date of service. Any line of the claim form where the MUE is exceeded will be denied.

In correspondence sent to AAOMS and other medical specialty organizations, the Centers for Medicare and Medicaid Services (CMS) explains that the MUE UOS edits are based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, CMS policies, nature of service/procedure, nature of equipment, and clinical judgment. The purpose of the edits is to prevent overpayments resulting from the reporting of excess units of service due to entry errors, incorrect interpretation of HCPCS/CPT codes, etc.

Since 2007, Medicare has adjudicated each line of a claim separately against the MUE value for the code on that line. By adjudicating claims in this fashion, the appropriate use of some modifiers (e.g., 76, 59, 91, anatomic) may bypass an MUE value because the modifier causes the HCPCS/CPT code to appear on separate lines of the claim each adjudicated separately against the MUE value for the code on that line of the claim. CMS has an appeals process in place to ensure payment for medically reasonable and necessary services that exceed established MUEs. Providers may appeal MUE criteria denials by forwarding a request to the carrier to forward the appeal to the National Correct Coding Contractor, if the carrier agrees with the appeal.

CMS does not believe these edits are controversial as the system was designed to reduce unlikely situations, for instance the removal of three cataracts on the same beneficiary on the same date of service when anatomically a person only has two eyes. CMS advises that providers should continue to only report services that are medically reasonable and necessary.

CMS announced in early February 2013 that some MUE's will become Date of Service (DOS) edits where possible. The Government Accountability Office (GAO) and Office of Inspector General (OIG) have performed studies which proved that some providers were reporting the same code on more than one line item of a claim form which is inappropriate. The GAO has now recommended that MUE's be changed to date of service edits replacing the current claim line edits. Those MUE's that would be changed to DOS edits would be assigned to one of two categories:

  1. A HSPCS/CPT procedure code that would "almost never" be reported with more units of service (UOS) than the MUE's
  2. HCPCS/CPT codes that would rarely, if ever, be paid for more UOS than the MUE value.

Note: Those who code correctly should not be impacted by this MUE program change.

CMS plans to implement the first DOS MUE's in the April 1, 2013 version of MUE. One common coding error made while reporting MUEs would be with the use of the modifier -50 for bilateral procedures. CMS requires providers (except ambulatory surgical centers ASC) to report a bilateral surgical procedure on a single claim line with the modifier -50 and only 1 UOS. By properly reporting bilateral surgical procedures according to CMS requirements, the number of claim denials due to DOS MUEs will be reduced. An MUE claim denial based on a DOS MUE may be appealed in the same manner as current claim denials.

The Committee on Healthcare and Advocacy will continue monitoring the development of MUEs and reviewing future versions as they are made available. As of October 1, 2011, CMS began updating the MUE values on its website on a quarterly basis coincident with every quarterly MUE update.

»CMS MUE Website
» December 8, 2006 MLN Matters