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Medically Unlikely Edits: Avoid denials and appeals by properly coding the first time

First Coast is receiving appeals for denials of services in which the provider did not bill the initial claim with the appropriate number of units based on Medically Unlikely Edit (MUE) values. Many of the appeals filed for MUE denials denied due to an MUE adjudication indicator (MAI) 2 edit. MAI 2 is an absolute date-of-service limit that can’t be overridden or bypassed with a modifier. Since MAI 2 is a date-of-service edit and is absolute (will never change), these denials cannot be overridden or overturned by the Medicare Administrative Contractor (MAC).

MUE values are not utilization guidelines. They do not represent units of service reported without concern about medical review. Continue to report reasonable and necessary services.
Please visit the CMS Medically Unlikely Edits page to search for MUEs that affect your claims. If you want to submit a request for reconsideration of an MUE value, please include your rationale and any supporting documentation. 

What’s a MUE?

CMS developed MUEs to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS or 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. CMS publishes most MUE values on its website; however, some MUE values are confidential. 

There are three types of MUE tables: 

  1. Practitioner services
  2. Durable medical equipment
  3. Facility outpatient hospital services 

Part B MUEs are in the practitioner file. The table contains four columns:

  • HCPCS / CPT code: Contains code with MUE value.
  • Practitioner services MUE values: Maximum units of service a practitioner would report under most circumstances for a beneficiary on a single date of service.
  • MAI: Describes the type of MUE (claim line or date of service), or logic behind the edit.
    • MAI 1: Edit is a claim line MUE - Appropriate use of modifiers to report the same code on separate lines of a claim will enable the reporting of medically necessary units of service in excess of.
      • MUE modifier examples: 76, 77, 91, RT, LT, F1, F2
    • MAI 2: Absolute date of service edits; per day edits based on policy - CMS has not identified any instances in which a higher value is payable. Since MAI 2 is a date-of-service edit and is absolute, these denials cannot be overridden or overturned by the MAC. Justification would be almost impossible as shown in the example below:
      • For example, an appendectomy has an MUE of 1 and MAI of 2. The maximum unit billable for an appendectomy is one because a patient only has one appendix.
    • While this example shows how MAI 2 prohibits billing the medically impossible, MAI 2 might also help avoid an error that is systematically impossible (e.g., CPT code 17000 used for lesion destruction states in the definition "first lesion"). By definition, it would be impossible to bill anything other than one unit of service. Additional units of service for lesion destruction would be billed with the add-on code +17003 or code 17004.
    • MAI 3: Per day edits based on clinical benchmarks - Value unlikely to appear on correctly coded claim but could, in unusual circumstances, be payable; exceptions are rare and supporting documentation required.
  • MUE rationale: Provides underlying basis.

If the number of units is over the MUE value, all units are denied. These denials may be appealed with supporting documentation. Note: Keep in mind that you cannot appeal denials with an MAI 2. 

Edit tips

Review these important points:

  • If you report a code with units greater than the MUE value assigned, the line or claim will deny
  • Be aware of the description of a HCPCS or CPT code when billing a service:
    • Initial
    • Subsequent
    • Single level
    • Second level
  • Many HCPCS and CPT codes have common or similar terms, but there are differences in the description. Some examples include:
    • Bilateral
    • Unilateral
    • Greater than
    • Less than
    • With
    • Without
  • MUEs do not exist for all HCPCS and CPT codes
  • Records should explain why the patient required more than the approved MUE for any service
  • Documentation submitted must support the units of service billed as reasonable and necessary
  • When billing, append the appropriate modifiers
  • While the majority of MUEs are publicly available on the CMS website, CMS will not publish all MUE values because of fraud and abuse concerns
  • CMS updates MUEs quarterly

What should you do to prevent unnecessary denials?

Many MUE denials are a result of incorrect billing. If you encounter a code with frequent denials due to an MUE, ensure the following:

  • Submit records with the claim to support the medical necessity of the number of services reported
  • The denial is NOT MAI 2. These denials cannot be overridden or overturned by the MAC.
  • The HCPCS / CPT code reported is correct
  • The units of service were counted correctly
  • An applicable and appropriately documented modifier was submitted, and
  • The numbers of services reported were medically reasonable and necessary. 

Be sure to report modifiers and units of service appropriately:

  • Example: Do not report modifier 76 on multiple claim lines, to avoid duplicate claim line denials. Instead, report multiple units of service when appropriate.
  • See examples in our modifier 76 fact sheet.

 

References