Wiki Appeal Tip Of The Week 6/4/12-6/8/12

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martinni1974

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What Are MUE's Anyway.....

The Medically Unlikely Edits (MUEs) were developed by the Centers of Medicare and Medicaid (CMS) to prevent inappropriate payment of services that should not be reported for multiple units for the same date of service. The MUEs reflect the maximum number of units of service that a provider might report under most circumstances for the same HCPCS/CPT code, for the same beneficiary, on the same date of service.

We recieve many claims everyday that deny for this reason. Here is an example below:

CPT code 59425 is defined as, "antepartum care only; 4-6 visits". This code is already valued for 4-6 visits. Many providers append multiple units to this code despite the fact that the code definition and RVU already reimburses for the number of visits in the code definition. Editing software will pick up this discrepency and cause your claim to deny.

When appealing make sure to read the full code definition in the year CPT book that correlates to your date of service as well as verify the MUEs. If you find yourself in a quandry take a look again at your documentation and how it matches up to your coding.

You may have chosen a wrong CPT or have a typo in the units field on your HCFA.

Happy Appealing
 
Multiple appeals are costly on both sides of the desk.

On the provider side the staff time it takes to prepare multiple appeals is costly and on the payer side at least 4 or more people have to handle the appeal which is also costly. Providing these tips is a win win for us all!

Have a wonderful day!
 
martinni1974 said:
We recieve many claims everyday that deny for this reason. Here is an example below:

CPT code 59425 is defined as, "antepartum care only; 4-6 visits". This code is already valued for 4-6 visits. Many providers append multiple units to this code despite the fact that the code definition and RVU already reimburses for the number of visits in the code definition. Editing software will pick up this discrepency and cause your claim to deny.
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As a coding student, I would appreciate if someone could explain if this means that on the 4th visit, and only that visit, you would code the 59425, and it wouldn't be until you go past that (i.e. the 7th visit), that you would then code the 59426. If so, how do you code visits 5 and 6?
 
59425-59426

Our office keeps track of each time the patient has an antepartum vivist. 59425 - 1 59425 - 2 59426 - 8 etc. If the patient leaves the practice before she delivers we code the level to how many visits. 8 visits we code 59426 with a notation of why we are billing the antepartum. If the patient had 5 antepartum visits we code 59425. If the patient only had 3 visits, we code the appropriate EM codes for each visit. We do not bill the insurance until the patient either delivers or leaves the practice for this pregnancy. Hope this helps.
 
Thanks, Robin. It definitely clears things up and makes sense now that I think it through.
 
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