Wiki MUEs

[tworrock]

Hello everyone,

Can someone please help me understand MUEs? I understand for Medicare there are caps on units that you can bill... but I don't know how to find these for other private payers. Can someone point me in the right direction or enlighten me on MUEs?

Thank you!

 

[sls314]

Hello everyone,

Can someone please help me understand MUEs? I understand for Medicare there are caps on units that you can bill... but I don't know how to find these for other private payers. Can someone point me in the right direction or enlighten me on MUEs?

Thank you!

MUEs are part of CMS NCCI - most private payers follow CMS. To my knowledge, there aren't any private payer specific MUE lists.

This is semantics, but remember that MUE = Medically Unlikely Edit. It's not a cap on the number of units you can bill. Sometimes it effectively acts that way, but there are times where you can appeal to have more units paid than the MUE. If there's documentation that the service was both rendered and medically necessary.

This CMS MLN Matters Document mentions when an MUE can be appealed: https://www.cms.gov/files/document/...edically-unlikely-edit-mue-program-mm8853.pdf

 

[tworrock]

Wow, thank you so much! So is it allowable to bill over Medicare's MUE for private payers? In every other finance position I've worked in, you bill for the exact service that was rendered. If the payer will ONLY pay for 10 out of 30 units billed, you would have to write off the rest. Most financially efficient way though is to only render services for units you know will gert paid (i.e. only render 10 units if you know only 10 units will get paid). Is that correct?

Best example is 95145-95149. Can you ONLY bill max 10 units for all payers? We have 13mL vials and each dose is 1mL so it really should be billed for 13 units, right?

 

[sls314]

Wow, thank you so much! So is it allowable to bill over Medicare's MUE for private payers? In every other finance position I've worked in, you bill for the exact service that was rendered. If the payer will ONLY pay for 10 out of 30 units billed, you would have to write off the rest. Most financially efficient way though is to only render services for units you know will gert paid (i.e. only render 10 units if you know only 10 units will get paid). Is that correct?

Best example is 95145-95149. Can you ONLY bill max 10 units for all payers? We have 13mL vials and each dose is 1mL so it really should be billed for 13 units, right?

Most private payers will follow CMS NCCI, including MUEs. If more units than the MUE are billed, the only way to potentially get them paid is to show documentation demonstrating why the units billed were medically reasonable and necessary. You'd have to appeal the claim with appropriate documentation. (It's not an automatic exception, but I have occasionally seen claims get paid after appeal of the MUE. My personal examples all relate to pathology.)

You can only bill for the units that were provided to a patient. I'm not sure whether your patient is receiving 13 mL, or whether your patient is receiving 10 mL with 3 mL from the vial being wasted. If there's a documented medically necessary reason that 13 mL were provided to the patient, then I'd appeal with the documentation to support that.

95145-95149 have an MUE Adjudication Indicator of 3 (Date of Service Edit: Clinical), which means they are per day edits based on clinical benchmarks, and can be appealed. The PDF I linked above explains the adjudication indicators.

 

[tworrock]

Most private payers will follow CMS NCCI, including MUEs. If more units than the MUE are billed, the only way to potentially get them paid is to show documentation demonstrating why the units billed were medically reasonable and necessary. You'd have to appeal the claim with appropriate documentation. (It's not an automatic exception, but I have occasionally seen claims get paid after appeal of the MUE. My personal examples all relate to pathology.)

You can only bill for the units that were provided to a patient. I'm not sure whether your patient is receiving 13 mL, or whether your patient is receiving 10 mL with 3 mL from the vial being wasted. If there's a documented medically necessary reason that 13 mL were provided to the patient, then I'd appeal with the documentation to support that.

95145-95149 have an MUE Adjudication Indicator of 3 (Date of Service Edit: Clinical), which means they are per day edits based on clinical benchmarks, and can be appealed. The PDF I linked above explains the adjudication indicators.

Thank you so much.
That makes sense! For the 95145-95149, it's just how the vials are ordered from the manufacturer. It would be 13mL total given to the patient with no waste.

 

[amyjph]

Agree with Susan