Maryann C. Palmeter CPC, CPCO, CPMA, CENTC, CHC

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Maryann C. Palmeter CPC, CPCO, CPMA, CENTC, CHC

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Maryann C. Palmeter CPC, CPCO, CPMA, CENTC, CHC Dont Chase Your Tail Over Medically Unlikely Edits Disclaimer This presentation is for general education purposes only. The opinions expressed during this presentation are those of the

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Maryann C. Palmeter
CPC, CPCO, CPMA, CENTC, CHC Don’t Chase Your Tail Over
Medically Unlikely Edits

Disclaimer This presentation is for general education purposes only. The opinions expressed during this presentation are those of the speaker and not her employer. All efforts were made to have the most current information available at the time of this presentation. Please note that laws, regulations and payer policies pertaining to the subject matter of this presentation are subject to change and interpretation.

CPT® codes and descriptions are copyright 2024 American Medical Association. All Rights Reserved.

Objectives Discover what a MUE is
Locate MUE tables & learn how to interpret them
Compare Claim Line Edits & Date of Service Edits
Grasp proper modifier usage
Uncover differences between payers
Determine next steps for denials

MUE vs. Mew Has nothing to do with felines
MUE is an acronym for “Medically Unlikely Edits”
CMS developed the MUE program to reduce the Medicare Part B paid claims error rate
Separate MUE table for Medicaid

MUE Table Sets Medicare DME Supplier
Facility Outpatient
Practitioner
Mystery Edits Medicaid DME
Outpatient Hospital Services
Practitioners & ASC Services

MUE Files MUE files are updated at least quarterly. Here is a link to the MUE page on CMS’ website:

Medicare NCCI Medically Unlikely Edits | CMS

MUE Files MUE files are updated at least quarterly. Here is a link to the Medicaid MUE page:

Medicaid NCCI MUE Archive | CMS

MUE Table The MUE Table lists the HCPCS/CPT® code, the MUE value, the MUE Adjudication Indicator (“MAI”), and the MUE rationale

Medicare Table

Medicaid Table

MUE Values The MUE Values column lists the maximum number of units per claim line or date of service.

MUE Adjudication Indicator Each MUE has a “MUE Adjudication Indicator” (MAI) which categorizes the MUE as a line edit or a date of service edit.

MUE Table Example CMS Practitioner Services MUE Table effective October 1, 2024
CPT only copyright 2024 American Medical Association. All rights Reserved

One Line Edit MAI Edits applied on detail line basis
If units exceed MUE Value, all units on claim line will deny

Table 1 CMS Practitioner Services MUE Table effective October 1, 2024

Date of Service MAI 2 edits Apply to units billed on all lines of a claim for same DOS and patient
Edits adjudicated based on total units on claim for same service on same DOS
Extremely unlikely that more units than the MUE value would ever be performed on the same DOS for same patient
Per date of service edits based on policy

Bilateral Procedures Do not report with units greater than “1”
Do not report on separate detail lines with anatomic modifiers

Report as follows:

Procedure Modifier Units
15822 50 1

Append bilateral surgery modifier to procedure code. CPT only copyright 2024 American Medical Association.
All rights Reserved

Date of Service MAI 3 edits Based on clinical benchmarks
Rationale may be CMS policy, anatomic considerations, or data driven
Ensure adequate documentation of clinical appropriateness for correctly reported units when appealing denials

Edit Rationale MUE tables include Edit Rationale for each HCPCS/CPT® code
Only one rationale displayed in table but more than one may apply

Edit Rationale – Clinical: Data One of the listed Edit Rationales for MAI 3 edits is clinical data
This rationale indicates that 100% of Medicare Part B claims data from a six-month period of time was the major factor in determining the MUE value

Table 6 FDA Prescribing
Information CMS Practitioner Services MUE Table effective October 1, 2024

What’s Wrong With This Claim? Patient’s DOB: 10/19/1951
DOS: 01/16/24
Diagnosis: R63.1 (Polydipsia), R63.4 (Abnormal weight loss), R35.1 (Nocturia)
Procedure: 82951 (Glucose; tolerance test [GTT], 3 specimens [includes glucose])
Fasting glucose followed by tests at 1 and 2 hour intervals.
Units Billed: 3 CPT only copyright 2024 American Medical Association. All rights Reserved

You Make the Call What do you think the maximum number of units per date would be for the following procedure code?

41828 Excision of hyperplastic alveolar mucosa, each quadrant, (specify) CPT only copyright 2024 American Medical Association.
All rights Reserved

Modifier Usage The appropriate use of CPT® modifiers (e.g., 25, 58, 59, 76, 77, 91) or HCPCS Level II modifiers (e.g., E1, FA, LC, LT, RT, XE) to report the same code on separate lines of a claim will enable a provider or supplier to report medically reasonable and necessary units of service in excess of an MUE

Modifier Usage Modifier 59 identifies procedures/services, other than E/M services and radiation treatment management, which are not normally reported together, but are appropriate under the circumstances. Documentation must support:
a different session;
different procedure or surgery;
different site or organ system;
separate incision/excision;
separate lesion; or
separate injury (or area of injury in extensive injuries)

Modifier Usage XE – Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
XS – Separate Structure, A service that is distinct because it was performed on a separate organ/structure
XP – Separate Practitioner, A service that is distinct because it was performed by a different practitioner
XU – Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service Don’t forget about these modifiers:

Date of Service MAI 2 Edit Example Patient: Billy Billingsley
DOS: 07/02/24
Dx: Acute respiratory failure with hypoxia
POS: 21
Procedure: 94002 Units: 2
Provider: Orville Wrong, M.D. What’s wrong with this claim?
94002 - Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day CPT only copyright 2024 American Medical Association.
All rights Reserved

Application to Medicaid & Private Payers Medicaid “sort of” adheres to CMS’ National Correct Coding Initiative (NCCI) and part of that initiative is the Medically Unlikely Edits
Private payers often adopt CMS’ NCCI edit logic
Review your contracts and commercial payer policies
Watch your remittance vouchers closely

MUE & ABN Did you know that a patient may not be billed (even if a valid Medicare Advance Beneficiary Notice (ABN) was given) if a charge is denied as a result of a Medically Unlikely Edit (MUE)?

MUE & ABN The reason is…
MUE are not utilization edits
A denial of services due to an MUE is a coding denial, not a medical necessity denial
The presence of an Advance Beneficiary Notice (ABN) will not shift financial liability to the patient for units of service denied based on an MUE

Denial Next Steps Was the HCPCS/CPT® code reported correctly;
Were the units of service counted correctly (e.g., per joint vs. per nerve);
Was an applicable and appropriately documented modifier submitted; and
Were the number of services reported clinically appropriate?

Denial Next Steps Why does the provider’s practice differ from national patterns?
Is any variance legitimate?
Check with relevant specialty society
Appeal denied service(s) to local MAC
Request update to MUE edits

Contacts Requests for reconsideration of an MUE value should be sent to the following email address: NCCIPTPMUE@cms.hhs.gov.
Inquiries about a specific claim should be addressed to the local MAC.
Inquiries about the rationale for an MUE value should be addressed to your MAC or a national healthcare organization whose members often perform the procedure.

Questions? Follow the rules for Medically Unlikely Edits
and you will be purring like a kitten!

Maryann C. Palmeter CPC, CPCO, CPMA, CENTC, CHC

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