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MUE program sets payment limits


Though the Medically Unlikely Edits program began in 2007, many providers are still unfamiliar with the intent and mechanism of this project, which aims to reduce the rate of erroneously reported Medicare claims.


Though the Medically Unlikely Edits program began in 2007, many providers are still unfamiliar with the intent and mechanism of this project, which aims to reduce the rate of erroneously reported Medicare claims.

Dr. Freeman

coding.doc By L. Neal Freeman, MD, MBA

Ophthalmologists are now accustomed to the new environment of coding and reporting limits imposed by various payers. One of the less-recognized, but nonetheless important, programs that moves Medicare further in that direction is the Medically Unlikely Edits (MUE) initiative.

The MUE program began in 2007, but many providers are still unfamiliar with the intent and mechanism of this project. The stated intent of the program is to reduce the rate of erroneously reported Medicare claims.

These edits are generated by the same contractor responsible for National Correct Coding Initiative (NCCI) edits. Many providers know the NCCI edits as the “bundling” edits. Your local Medicare contractor enforces the edits.

The Centers for Medicare and Medicaid Services (CMS) website (http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html) addresses this program. At this site, the program is described and a link to MUE values for practitioners is provided.

How it works

The basic concept behind this program is the edits place maximums on the number of units of service per code that can be reported by a provider for the same beneficiary on the same date of service. Any claim line where the “claim line MUE” value is exceeded will be denied.

The edits are established based on various factors, such as anatomic considerations and customary medical practice. These edits have not been generated for all CPT codes, however.

The medically unlikely edit value for total splenectomy (CPT 38100) is “1,” because we have only one spleen.

A substantial majority of ophthalmic procedure codes carry an MUE value of “1.” There are some exceptions, such as some strabismus and oculoplastics codes.

The MUE program is a prepayment program. This means the service will be denied before payment is generated. The program applies to all Part B services, including ambulatory surgery center and hospital outpatient claims. Patients may not be balance billed following a denial based upon an MUE.

Bilateral procedures should be reported with the -50 modifier to Medicare. Therefore, bilateral trabeculoplasty on a given date of service would be reported on one claim line as CPT 65855-50 with one unit of service. This would pass the edit screen, because the MUE value for 65855 is “1.”

CMS has chosen not to publish all the MUE values against which it adjudicates claims. The stated intent of this policy is to prevent fraud. The apparent concern is that publication of high MUE values might encourage unscrupulous providers to report services at high volume, knowing that the edit will not be surpassed.

Types of MUEs

There are two varieties of MUEs.

  • The first is known as a “claim line” or “unit of service” edit. With a claim line edit, each line of a claim is compared with the MUE value. Claim lines for which the reported units of service are no greater than the MUE value will pass the edit.
  • As of April 2013, a new type of MUE known as a “date-of-service” edit was created. With this type of MUE, the total number of units for a given code reported for a single date is compared with the edit value. Passing the edit requires that the total units for the given date does not exceed the listed value, regardless of the number of claim lines used to report the service.

The list of codes subject to date-of-service edits, as opposed to claim line edits, is not released by CMS.

In situations where it is medically appropriate to report services in excess of a claim line edit, the edit may be bypassed with the use of particular modifiers. For example, a patient undergoing anterior chamber paracentesis of the right eye that needs a repeat paracentesis that day could be reported as 65800-76.

There is a mechanism by which these edits may be changed. However, the recommended first step is to contact a major ophthalmic organization, such as the American Academy of Ophthalmology, as it may be able to provide insight to the rationale for the edit value. Edit values are revised quarterly by CMS.

It will be well worthwhile to follow developments in this program, in addition to others that potentially limit reimbursement for services.

L. Neal Freeman, MD, MBA, is president and founder of CPR Analysts, Melbourne, FL (http://www.cpranalysts.com/). He advises physicians nationally on coding, reimbursement, and practice management. Dr. Freeman is a practicing ophthalmic plastic surgeon and a certified specialist in physician coding. Readers may contact Dr. Freeman at nfreeman@cpranalysts.com. CPT codes, descriptions, and other data only are copyright 2013 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.


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