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Medically unlikely edits creating cause for concern

Recovery Auditor Report, January 21, 2010

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Connolly Healthcare and CGI recently added Medically Unlikely Edits (MUE) for outpatient hospital claims to their CMS-approved list of issues. MUEs are edits that CMS has put into place to limit the number of units for a service for one patient on the same date of service. Currently, if a provider bills over that limit, the claim will be returned to the provider (RTP) and cannot be appealed.

MUEs are designed to prevent clerical errors and incorrect coding. Several years ago, the date of service and the units field on the UB04 were inadvertently switched. This resulted in costly overbilling errors by some providers. This may have been part of the reason for implementation of MUEs, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

Of the four RACs, Connolly and CGI, the RACs for Region C and B respectively, are the only ones to officially announce MUEs as an approved issue; however, HealthDataInsights, the RAC for Region D has released “once in a lifetime” edits as a RAC audit issue. Once in a lifetime edits are similar to MUEs as a unit of service limit, however, all of the patient’s claims history is considered rather than one date of service, said Mackaman.

With added focus on an already uncertain entity, being cautious and aware of these issues is crucial. “You have to look at all aspects of the revenue cycle in today’s regulatory environment,” Mackaman says. She suggests a number of items providers should consider when attempting to untangle the MUE web:

• Know where to find the appropriate MUE table on the CMS Web site
• Develop an understanding of the current and future CMS guidance to help bypass edits when the units of service are appropriate and discuss with your FI or MAC, if necessary
• Create a system to catch these edits prior to submitting the claim and review for possible errors
• Providers should watch for quarterly changes to the list in the future since CMS has not published all of the edits

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