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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Medically Unlikely Edits

January 5th, 2007

In ongoing efforts to stop inappropriate payments, the Centers for Medicare and Medicaid Services has implemented a new 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.

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 American Medical Association explains that the "MUE UOS edits are based on anatomic considerations, CPT code descriptors, CPT coding instructions, and medical reasonableness. 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."

While CMS states they are still exploring the need for claims modifiers to by-pass MUEs on a pre-payment basis in specific, medically reasonable and necessary situations, it is important to note that MUEs will be adjudicated on a claim line basis. Thus, if a procedure is repeated at a separate patient encounter on the same date of service, the provider may report the service on two lines, one line with the HCPCS/CPT code and a second line with the same code with modifier -76 appended. CMS plans to monitor potential abuses of MUEs where the provider bills multiple services incorrectly on different lines of a claim or on split claims. CMS has also stated that there will be an appeals process in place to ensure payment for medically reasonable and necessary services that exceed established MUEs.

CMS does not believe these edits will be 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. Unlike the NCCI edits, the MUEs are not available to the public, therefore accurate coding is crucial for proper claim adjudication.

The Committee on Healthcare and Advocacy will continue monitoring the development of MUEs and reviewing future versions as they are made available.