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Medically Unlikely Edits (MUEs)

CMS developed MUEs to reduce the paid claims error rate for Medicare claims. Just like the NCCI edits, the MUEs are automated prepayment edits that help prevent inappropriate payments. The Affiliated Contractors (ACs) / Medicare Administrative Contractors (MACs) systems analyze the procedures on the submitted claim to determine if they comply with the MUE policy.

An MUE for an HCPCS / CPT code is the maximum units of service that a provider would report, under most circumstances, for a single beneficiary on a single date of service. MUEs do not exist for all HCPCS / CPT codes. Prior to implementation of MUEs, national health care organizations are offered an opportunity to review and comment about proposed edits. While the majority of MUEs are publicly available on the CMS website, CMS will not publish all MUE values because of fraud and abuse concerns. CMS updates MUEs quarterly.

Providers should not interpret MUE values as utilization guidelines. MUE values do not represent units of service that may be reported without concern about medical review. Providers should continue to report only services that are medically reasonable and necessary.

1. How were  MUEs developed?

MUEs were developed based on HCPCS/CPT code descriptors, CPT coding instructions,  anatomic  considerations,  established  CMS  policies,  nature  of service/procedure, nature of analyte, nature of equipment, and clinical  judgement. All edits based on clinical judgment as well, as many others, were reviewed by workgroups of contractor medical directors.

Prior  to  implementation  of  MUEs,  the  proposed  edits  were  released  for  a  review  and  comment  period  to  the  AMA,  national  medical/surgical societies, and other national health care organizations, including  non-physician  professional  societies,  hospital  organizations,  laboratory organizations, and durable medical equipment organizations. MUE files are updated quarterly, including MUEs for additional codes.

2.  How are claims adjudicated with MUEs?

All CMS ACs/MACs adjudicate MUEs against each line of a claim rather than the entire claim. Thus, if an HCPCS/CPT code is reported on more than one line of a claim by using CPT modifiers, each line with that code  is separately adjudicated against the MUE.

ACs/MACs deny the entire claim line if the units of service on the claim line exceed the MUE value for the HCPCS/CPT code on the claim line. Since claim lines are denied, the denial may be appealed. Submit appeals to local ACs/MACs, not the MUE contractor, Correct Coding Solutions, LLC.

3.  How do I report medically reasonable and necessary units of service in excess of an MUE value?

Since  each  line  of  a  claim  is  adjudicated  separately  against  the  MUE value for the code on that line, the appropriate use of CPT modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g., -RT, -LT, -F1, -F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59  should  be  utilized  only  if  no  other  modifier  describes  the service. The medical record must include supporting documentation for the appropriate modifier.

4.  How are claim lines adjudicated against an MUE for a repetitive service reported on a single claim line?

Some contractors allow providers to report repetitive services performed over a range of dates on a single line of a claim with multiple units of service. If a provider reports services in this fashion, the provider should  report the “from date” and “to date” on the claim line. Contractors are instructed to divide the units of service reported on the claim line by the  number of days in the date span and round to the nearest whole number. This number is compared to the MUE value for the code on the claim line.

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