Don’t Chase Your Tail Over Medically Unlikely Edits

Don’t Chase Your Tail Over Medically Unlikely Edits

Avoid payer denials by ensuring your provider or supplier follows the rules for allowable MUE units.

Understanding why Medically Unlikely Edits (MUEs) were established, how they are organized, and the criteria on which edit rationales are based may help medical coders and billers avoid denials or, at a minimum, properly resolve a denial.

What Are MUEs?

The Centers for Medicare & Medicaid Services (CMS) developed the MUE program to reduce the Medicare Part B paid claims error rate. Edits are based on anatomic considerations, procedure code descriptors, CPT® instructions, CMS policies, the nature of a service or procedure, analyte, and equipment, CMS data, and clinical judgment. These edits are set to deny claim lines exceeding the acceptable maximum number of units on the same service date for the same patient.

CMS updates MUE files at least quarterly, which are available on the CMS’ website.

MUEs Come in Several Varieties

There are three tables or sets of edits: Durable Medical Equipment (DME), Facility, and Practitioner. It’s important to access the relevant edit set because the edits vary among sets. Physicians and other qualified healthcare practitioners use the Practitioner table. Some MUEs remain confidential out of concern for potential abuse and are not published.

MUE tables list HCPCS Level II/CPT® codes, MUE values, MUE adjudication indicators (MAIs), and MUE rationales.

The MUE Values column lists the maximum number of units per claim line or date of service. If the MUE value is listed as 0 (zero), the HCPCS Level II/CPT® code is invalid, not covered, bundled, not separately payable, statutorily excluded, or not reasonable and necessary in accordance with Medicare regulations or guidance. This is an area where private payers may have different rules because they may cover some of the services that Medicare does not.

Each MUE has an MAI that categorizes the MUE as a one-line edit or a date of service edit.

MUE tables also include MUE rationales for each HCPCS Level II/CPT® code. Although an MUE may be based on several rationales, only one is displayed in the edit table. One of the listed rationales is “Data.” This rationale indicates that 100 percent Medicare Part B claims data from a six-month period was the major factor in determining the MUE value.

One-line Edit MAIs

These edits are applied on a detail line basis. The units of service on each claim line are compared to the MUE value for the HCPCS Level II/CPT® code on that claim line. If the units exceed the MUE value, all units on that claim line are denied.

Table 1 illustrates a line edit for CPT® code 47539 Placement of stent(s) into bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation; new access, without placement of separate biliary drainage catheter. The MUE value is 2.

The introduction in the Biliary Tract subsection of CPT® specifies that CPT® code 47539 may be reported more than once in the same session using modifier 59 Distinct procedural service for additional procedures in the following circumstances:

  • Placement of side-by-side (double-barrel) stents within a single bile duct;
  • Placement of two or more stents into separate bile ducts through a single percutaneous access; or
  • Placement of stent(s) through two or more percutaneous access sites.

The above scenarios are the only time units of service should exceed one; with the maximum units being two only if one of the aforementioned exceptions is applicable.

Table 1: Line edit for CPT® code 47539

HCPCS Level II/
CPT® Code
Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale
47539 2 1 line edit Nature of service/Procedure

Date of Service MAIs

If the MUE is adjudicated as a date of service edit, all units on each claim line for the same date of service and HCPCS Level II/CPT® code are summed, and the sum is compared to the MUE value. If the summed units on the claim exceed the MUE value, all units for the HCPCS Level II/CPT® code for that date of service are denied. Date of service edits are used for HCPCS Level II/CPT® codes where it would be extremely unlikely that more units than the MUE value would ever be performed on the same date of service for the same patient.

Edits for HCPCS Level II/CPT® codes with an MAI of 2 are absolute date of service edits. These are per day edits, based on policy. Units of service on the same date of service in excess of the MUE value would be considered impossible because billing in this fashion would be contrary to Medicare statute, regulations, or guidance. For example, it would be contrary to correct coding policy to report more than one unit of service for CPT 94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day because there can only be one “initial day” for the same patient.

Table 2 illustrates the MUE values for procedure codes 17000, 17003, and 17004: premalignant lesions (e.g., actinic keratoses). It is inappropriate to report 17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion with units greater than 1 on the same service date for the same patient. The CPT® code definition stipulates this code to be reported for the first premalignant lesion, only. Additional premalignant lesions should be reported with a different CPT® code.

Table 2: MUE values for procedure codes 17000, 17003, and 17004

HCPCS Level II/
CPT® Code
Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale
17000

17003

17004

1

13

1

2 Date of Service Edit: Policy Code descriptor/CPT instruction

 

It is also inappropriate to report +17003 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) with units greater than 13 because the code description stipulates to report this code for the second through 14th premalignant lesion. Units may be adjusted up to 13.

Report additional premalignant lesions with CPT® code 17004 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions. Do not report 17004 with units greater than one because the code description stipulates 15 or more lesions. Report this code once for premalignant lesions greater than 14 that are destroyed on the same service date for the same patient.

Because CPT® codes 17000, 17003, and 17004 do not stipulate an anatomical location, it’s inappropriate to report modifier 59 with any of these CPT® codes.

Table 3 illustrates an MAI 2 edit based on CMS policy for 15822 Blepharoplasty, upper eyelid. Per CMS policy, do not report more than one unit of 15822 on the same date for the same patient without a modifier because the maximum units for this code is one. When this service is performed bilaterally, report 15822 on a single claim line and append modifier 50 Bilateral procedure. Report units as one. If performed unilaterally, append either the RT Right side or E3 Upper right, eyelid modifier when performed on the right side of the body, or the LT Left side or E1 Upper left, eyelid modifier when performed on the left side of the body. Report units as one for this scenario, as well.

Because the bilateral surgery indicator for this CPT® code is one, payment is based on either the lower of the sum of the actual charges for both procedures or 150 percent of the Medicare fee schedule amount for a single code. CMS policy for reporting bilateral surgical procedures is to report the procedure code on a single claim line with modifier 50 and one unit of service. When modifier 50 is required by manual or coding instructions, claims submitted with two lines or two units and anatomic modifiers are denied for incorrect coding.

Private payer policy may vary from Medicare’s policy.

Table 3: MAI 2 edit based on CMS policy

HCPCS Level II/
CPT® Code
Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale
15822 1 2 Date of Service Edit: Policy CMS Policy

 

Edits for HCPCS Level II/CPT® codes with an MAI of 3 are date of service edits. These are per day edits based on clinical benchmarks. The rationale may be CMS policy, anatomic considerations, or data-driven. If claim denials based on these edits are appealed, Medicare Administrative Contractors (MACs) may pay units of service in excess of the MUE value if there is adequate documentation of medical necessity for the reported units.

Table 4 illustrates an MUE value of 1 for 96003 Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle. The edit is based on the nature of the service. Specifically, CPT® code 96003 is for one muscle, so the units of service should not exceed one.

Table 4: An MUE value of 1 for 96003

HCPCS Level II/CPT® Code Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale
96003 1 3 Date of Service Edit: Clinical Nature of Service/Procedure

 

Some MUEs are date of service edits based on clinical information. Table 5 illustrates an MUE where the edit rationale is based on prescribing information. The maximum units of service are based on dosage for the patient type (i.e., adult vs. child). In this example, HCPCS Level II code J0500 Injection, dicyclomine HCL, up to 20 mg is for dicyclomine HCL or Bentyl®, up to 20 mg. The prescribing information lists the recommended intramuscular dose in adults as 10 mg to 20 mg, four times a day. The maximum units of service per day, per the prescribing information, is four. Doses in excess of this fall outside of the suggested dosage for adults.

Table 5: An MUE where the edit rationale is based on prescribing information

HCPCS Level II/CPT® Code Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale
J0500 4 3 Date of Service Edit: Clinical Prescribing Information

 

Modifiers Override Edits

Appropriately using CPT® modifiers (e.g., 25, 76, 77, 91, 59) or HCPCS Level II modifiers (e.g., E1, E4, F2, FA, LC, LT, RT) to report the same code on separate lines of a claim enable a provider or supplier to report medically reasonable and necessary units of service in excess of an MUE value.

Denial Types Dictate Actions

A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice of Noncoverage (ABN) will not shift financial liability to the patient for units of service denied based on an MUE.

MUE are not utilization edits. Although the MUE value for some codes may represent commonly reported units of service (e.g., MUE of 1 for appendectomy), the usual units of service for many HCPCS Level II/CPT® codes is less than the MUE value. Providers should continue to report services that are medically reasonable and necessary.

Claims processing contractors may have units of service edits that are more restrictive than CMS’ MUEs. In such cases, the more restrictive claims processing contractor edit is applied to the claim. Similarly, if the MUE is more restrictive than a claims processing contractor edit, the more restrictive MUE applies.

If a provider encounters a code with frequent denials due to an MUE or a modifier submitted to bypass an MUE, the provider or supplier should ensure:

  • The HCPCS Level II/CPT® code reported is correct;
  • The units of service were counted correctly (e.g., per joint vs. per nerve);
  • An applicable and appropriately documented modifier was submitted; and
  • The number of services reported were medically reasonable and necessary.

If the claim was submitted correctly and still denied, then perhaps it’s time to question why the provider’s practice differs from national patterns. Providers have the opportunity to request updates to the MUE edits, but they need to be prepared to submit supporting clinical and/or specialty society documentation with their request. Address inquiries about a specific claim to the local MAC. Address inquiries about the rationale for an MUE value to the local MAC or a national healthcare organization whose members often perform the procedure.

To submit a reconsideration request for an MUE value, send your request along with the proposed MUE value and supporting documentation to:

National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907, Carmel, IN 46082-0907
Fax #: 317-571-1745

Medicaid and Private Payers

Medicaid adheres to CMS’ National Correct Coding Initiative (NCCI) and MUEs. Private payers often adopt CMS’ NCCI edit logic into their claims systems. Review your contracts and commercial payer policies for guidance and watch your remittance vouchers (i.e., Explanation of Benefits) closely.


Resource

CPB : Online Medical Billing Course

MUE files are available on the MUE page on CMS’ website and updated at least quarterly: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

Maryann Palmeter

Maryann Palmeter

Maryann has over 30 years of experience in the healthcare industry with emphasis on federal and state government payer billing and compliance regulations. She is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance where she provides professional direction and oversight to the Billing Compliance Program of the University of Florida College of Medicine – Jacksonville. Maryann served on the AAPC's 2011-2013 National Advisory Board and the 2013-2015 Board as secretary. Palmeter currently serves the Jacksonville, Florida local chapter as education officer and has served as president, president-elect, and member development officer. Palmeter was named the AAPC’s 2010 “Member of the Year.”
Maryann Palmeter

About Has 22 Posts

Maryann has over 30 years of experience in the healthcare industry with emphasis on federal and state government payer billing and compliance regulations. She is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance where she provides professional direction and oversight to the Billing Compliance Program of the University of Florida College of Medicine – Jacksonville. Maryann served on the AAPC's 2011-2013 National Advisory Board and the 2013-2015 Board as secretary. Palmeter currently serves the Jacksonville, Florida local chapter as education officer and has served as president, president-elect, and member development officer. Palmeter was named the AAPC’s 2010 “Member of the Year.”

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