Corporate Compliance

Note from the instructor: CMS Updates Medically Unlikely Edits (MUE) File

Medicare Insider, July 15, 2014

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This week’s note from the instructor is written by Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro.  
Note from the instructor: CMS Updates Medically Unlikely Edits (MUE) File
A few weeks ago, CMS released MLN Matters article SE1422 titled Medically Unlikely Edits and Bilateral Procedures. Upon first glance, this MLN Matters article seems to be focused on certain claims with noncompliant coding for bilateral surgical procedures that may have triggered improper payments. In the past few years, the Office of Inspector General (OIG) has identified inappropriate billing using multiple lines to bypass the MUEs per CMS’ previous guidance in Transmittal 652. CMS states that the purpose of this article is to inform providers that MUE changes may now cause multiple claim lines for bilateral procedures to be “unpayable”. However, this article goes on to announce that as of July 1, 2014, dates of service, CMS is converting most MUEs into per day edits and that the MUE Adjudication Indicator (MAI) indicates the type of and basis for the MUE.
Since 2007, hospitals have been navigating the MUE minefield. The edit occurs when a provider bills more than the maximum units of service for a HCPCS/CPT code than would be reported under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE and CMS publishes most, but not all, MUE values on its website. Some MUEs have been deemed to be confidential and are only for the eyes of CMS and its contractors. This has been an irritant (to say the least) for providers since the implementation of MUEs but we are making progress in understanding how the files work.
In SE1422 and on the CMS MUE website, they describe two additional fields that have been added to the published MUE file. One field indicates whether each MUE is a claim line or date of service edit and the second field provides the rationale for each MUE.  More information about the rationale of the MUE is available in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1, Section V (Medically Unlikely Edits).  
CMS has defined the three MAIs as:
  • 1 = MUE is based on a line edit. Medically appropriate units of service in excess of the MUE may be reported on a separate line with an appropriate modifier and each line will process for payment.
    • Example: 49062, Drainage of extraperitoneal lymphocele to peritoneal cavity, open
  • 2 = MUE is based on a regulation or subregulatory instructions, including the instruction that is inherent in the code descriptor or its applicable anatomy. Providers should consider the initial claim or any denials for this type of edit to be either a clerical error or an error in the interpretation of the instructions. CMS has not identified any exceptions to this type of MUE.
    • Example: 49321, Laparoscopy, surgical, with biopsy
  • 3 = MUE is based on clinical information such as billing patterns, prescribing instructions, or other information, and exceptions beyond the MUE would be rare. Providers should review the initial claim or a denial for a clerical, coding, or billing error.
    • Example: 49082, Abdominal paracentesis without imaging guidance
For all MUE edit denials, and as an alternative to filing an appeal, if the provider identifies a clerical error and the correct value is equal to or less than the MUE, the provider may request a reopening to correct the claim. CMS cautions providers about routinely using this method to correct unintentional errors and that reopening requests do not extend the window for filing appeals.
All providers should review SE1422 for more information on the appropriate billing of bilateral surgical procedures, as well as review the other MUE examples that CMS has provided. 

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