Health Information Management

Q/A: Medically Unlikely Edits

APCs Insider, May 8, 2009

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Q. Why would we receive a Medicare edit for code 96361 (IV infusion hydration each additional hour) when we billed 21 hours of this service? The edit says “Units of service are in excess of the medically reasonable daily allowable frequency.” Where can we find a list of the allowable units?

A: CMS created Medically Unlikely Edits (MUEs) for the drug administration codes in the beginning of 2008. These were corrected in April 2008. CMS published many of the MUEs last year on the MUE information page. Unfortunately, the published edits do not include this code. Some of the edits remain unpublished because CMS considers them proprietary and is concerned that publication of these quantities will result in gaming of the system. If this is one of the unpublished edits there really is no way to research the “allowable units.”

You don’t specify whether the edit is in your internal scrubbing software or in the FI/MAC’s software. This language does not match the edit normally triggered with an MUE edit, so this may be a separate edit designed to identify extended hydration services that usually would not be expected for outpatient claims. The issue with this particular code is that an observation status patient could have an extended time for hydration services that are medically necessary, but this extended number of hours would be unexpected on a “regular” outpatient claim. Check the edit source—either your internal vendor or your FI/MAC—and ask the appropriate entity for any available information pertaining to the nature of the edit and allowable units.



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