Understanding medically unlikely edits : Maintain accurate and safe healthcare practices

The Centers for Medicare & Medicaid Services (CMS) established Medically Unlikely Edits (MUE) as a mechanism to restrict the frequency with which a specific service may be billed by a single provider to an individual patient on any particular date of service. The implementation of these unit-of-service edits commenced in 2007, aimed at mitigating payment inaccuracies related to Medicare Part B claims.

CMS characterizes an MUE as “a unit of service … edit for a [HCPCS]/[CPT] code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. ” It is important to note that not all codes possess an MUE. CMS has disseminated a partial compilation of MUEs on its website. Initially, this MUE inventory was exclusively accessible to Medicare carriers and was not available to the general public whatsoever. CMS maintained that the list was not designed to serve as a resource to aid providers in ascertaining the permissible number of service units billable on any specific day.

The establishment of the MUE procedures list is predicated upon anatomical considerations, code descriptions, CPT guidelines, CMS policies, the nature of the service/procedure, and clinical discretion. CMS assembled a list that underwent evaluation by external medical entities to ascertain the likelihood of a provider billing for a procedure within a given day. For example, code 64445 (Injection[s], anesthetic agent[s] and/or steroid; sciatic nerve, including imaging guidance, when performed) is eligible for bilateral billing, thereby establishing an MUE limit of two.

Accompanying the partial MUE list, CMS provided guidance on how providers can circumvent denials, the conditions under which they may override the edits using a modifier, and the procedure to appeal a denial.

The MUE list is not intended to function as usage guidelines devoid of consideration for medical necessity. Providers are to report only those services that are clinically rational and essential.

Utilize the MUE list to prevent errors

You are equipped with an additional resource to avert denials and overpayments arising from claims that surpass the permissible service volume, per patient, per day, including the incorrect reporting of bilateral procedures. Medicare has incorporated two columns into its MUEs for Correct Coding Initiative (CCI) version 20.2—MUE adjudication indicator (MAI) and MUE rationale—to facilitate the identification of gaps in staff expertise and to assess whether an appeal is feasible when your carrier denies a claim predicated on MUEs.

In tandem with the revised MUE list, CMS MLN Matters SE1422 advises providers that when they report a bilateral procedure lacking the term bilateral in the descriptor, they should report the service on a single line utilizing modifier -50 (Bilateral procedures). There are various methods for reporting a bilateral service; therefore, Medicare clarifies that it solely requires the service to be reported with modifier -50.
For instance, trigger point injection CPT code 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) carries a bilateral modifier indicator of “0,” signifying it cannot be billed bilaterally. Under the CCI edits, it possesses an MUE value of 1 and an adjudication indicator of 2 (date of service edit: policy). Policy edits derive from the information inherent in the code’s descriptor or the relevant anatomy. The justification for the edit is grounded in the code descriptor/CPT instruction. The carrier will revise claims according to the date of service and will deny further trigger point injections, even when documented on a subsequent line.

Medicare has indicated that it has not identified any occasions in which an exception to an edit with MAI 2 could be warranted, hence appeals against these denials will not be feasible. Alternatively, these denials should be utilized to educate staff on avoiding future errors.

Peripheral nerve block injection CPT code 64450 (Injection[s], anesthetic agent[s] and/or steroid; other peripheral nerve or branch) features a bilateral modifier indicator of “1”—payment adjustment for modifier -50 permitted—an MUE of 10, and a MAI of 3 (date of service edit: clinical). The rationale is substantiated by clinical data.

Medicare asserts that MAI 3 is the predominating date of service edit, with the MUE being informed by factors such as billing practices. Denials for these claims may arise from misinterpretation of coding instructions or medically unnecessary services. Nonetheless, Medicare does recognize that these MUEs may allow for infrequent exceptions and will permit providers to appeal denials.

To avert modifier -50 denials, request that your clinicians specify the anatomical side they are addressing. Moreover, monitor your private payers for any changes. Private payers who currently adopt Medicare’s CCI edits may also implement this policy.

Billing services that exceed MUE limits

If your pain physician executes a procedure surpassing the MUE limits, yet contends the procedure was medically necessary, you may potentially receive payment by appending a modifier to your claim, according to CMS guidelines. However, verify the MAI for codes to prevent denials that would be challenging or impossible to contest. Examine the MAI within your MUE file and flag codes with an MAI of 2 and 3.

MAI 2 codes, such as trigger point injections (CPT codes 20552-20553), are ineligible for appeal.

The CCI policy manual designates MAI 2 codes as absolute date of service edits. Billing more services than the prescribed MUEs on a single date of service “would be regarded as impossible due to its contravention of statute, regulation, or sub-regulatory guidance. ” Furthermore, an override of the edit during “processing, reopening, or redetermination would contravene CMS policy. ” Therefore, disseminate information regarding MAI 2 codes to your coding and clinical staff and remind them that MUE denials for these codes will persist.
MAI 3 codes, including joint injections (CPT codes 20600-20611), are open to appeal. Nonetheless, you should anticipate that your documentation will undergo meticulous examination at the initial level of appeal. Medicare mandates that the carrier possess substantiating evidence, such as a medical review, demonstrating that the service that surpasses the MUE was administered, accurately coded, and deemed medically necessary prior to the possibility of overriding the edit. Should you plan to utilize modifier -59 (Distinct procedural service), ensure that the services comply with the criteria outlined in the CCI manual.

FREE CPT Code Search Tool (Click Here)

MUST BUY CPT & ICD-10 CM  CODING EBOOKS 

MUEs and Advance Beneficiary Notice

An Advance Beneficiary Notice (ABN) cannot be employed in conjunction with a denial resulting from an MUE to recover the denied charges from the patient. A provider who anticipates that a service will be rejected by Medicare on grounds of medical necessity and wishes to bill the patient for the services must secure the patient’s signature on an ABN prior to the execution of the services, as well as inform the patient that they will be responsible for charges should the service not be covered by Medicare.

Per CMS, excess charges resulting from units of service exceeding the MUE may not be invoiced to the patient, and the charges denied due to the MUE cannot be subject to an ABN.