Medicare Compliance & Reimbursement

Question: We mostly see Medicare Part B beneficiaries at our practice and understand that this means that we need to understand how medically unlikely edits (MUEs) apply to our claims. We wondered, are there any situations in which we can override an MUE?

AAPC Forum Participant

Answer: In certain scenarios, if the physician performs a legitimate, medically necessary procedure that violates MUE edits, you may be able to still get paid from Medicare, despite the MUE.

Reminder: “Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims,” notes Centers for Medicare & Medicaid Services (CMS) guidance. “An MUE for a

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. Not all HCPCS/CPT^® codes have an MUE.”

Breakdown: CMS states that MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have, so you shouldn’t need to override them often. But in very specific circumstances, you can override an MUE when your physician performs and documents a medically necessary number of services that exceed the limit. Check your payer’s reporting preference.

The MUE table includes a column for “MUE Adjudication Indicator” (MAI), which provides guidance about what circumstances allow you to override an MUE limit for a given code. If the code has an MAI of “1,” the code is adjudicated on a claim-line basis, meaning that you can’t exceed the number of MUE units on a claim line. You are allowed to use one of the distinct-service modifiers (such as modifier 59 or the “X” modifiers) to override the edit, if circumstances warrant.

An MAI of “2” means that the frequency limit is absolute for a date of service — you cannot override the edit with a modifier.

An MAI of “3” means that the frequency limit is based on the date of service, and Medicare will automatically deny any claims in excess of that limit, even if you use an appropriate modifier. However, Medicare will consider an appeal with appropriate documentation. You also may need to supply documentation showing medical necessity for the additional units.