Pathology/Lab Coding Alert

Question: I-ve heard that Medicare has new edits called MUEs that are similar to CCI edits. What are they?


Iowa Subscriber
Answer: Medicare has indeed implemented a new set of edits called MUEs--Medically Unlikely Edits. The edits began Jan. 1, 2007, with new edits phased in quarterly.

Rather than pairing different codes, as the national Correct Coding Initiative (CCI) edits do, MUEs limit the number of units of a specific code that you can report for the same patient on the same day.

Also unlike CCI edits, Medicare does not publish the MUEs. Although CMS allows the AMA and professional societies such as the College of American Pathologists to view and comment on proposed MUEs, the final edits are a -black box- for all concerned.

Although you can't know for sure which codes have an MUE or what the unit -cap- is, four facts may help you decipher when you-ve had a claim denied due to the MUEs and what you can do about it:

1. For hospitals, Medicare will -Return to Provider- (RTP) the entire claim and not allow an appeal.
2. For providers such as pathologists and independent labs, Medicare will deny the claim line that exceeds an MUE but pay the rest of the claim and allow an appeal.
3. Medicare denial code C0151 (Payment adjusted, info submitted does not support this many services) may signal an MUE problem.
4. You cannot currently override an MUE with a modifier, although CMS has indicated that it may consider allowing that in the future.