Last week was another light week at CMS so I wanted to go back to a previous transmittal that was released on August 12. Even though One Time Notification Transmittal 949 was released to announce a correction to the Medicare contractors’ files, it also provided some valuable insight for providers on how MUEs work in the Medicare claims processing system. Most of the information is not new; however, some students who attend a boot camp are unaware of this CMS approved “work around.”
MUEs were initially released back on October 1, 2008, and have since been updated on a quarterly basis. Unfortunately, not all of the edits are made public for provider review. CMS has stated that some MUEs are not published because they are considered “confidential” and are only for use by CMS and its contractors. This has been a bone of contention between providers and FIs/MACs since their debut. I would have to agree that withholding some edits puts providers at a disadvantage and wastes valuable time and money because providers have to play a guessing game when appropriately submitting individual lines of the same CPT code; but that issue could be an entire blog post all by itself.
The purpose of the MUEs is to help CMS reduce the paid claims error rate due to clerical errors and incorrect coding based on a variety of factors, such as anatomy, HCPCS code descriptions and coding instructions, CMS policy, and unlikely diagnostic or therapeutic services. By definition, an MUE is a unit of service limit for a HCPCS/CPT code that a single provider renders to a single patient on the same date of service. The NCCI contractor, Correct Coding Solutions LLC, maintains the table based on a CMS requirement that the units of service limit for each MUE is set high enough, based on claims data, to allow for medically likely daily frequencies of that service.
Prior to April 1, 2010, MUEs created an ‘RTP’ situation for providers where the line that had the CPT code in excess of the MUE was rejected and returned to the provider to correct and resubmit. Since that time, CMS contractors will auto-deny the line with the units of service in excess of the MUE which means that the line can be appealed. This change was good news for providers; however, it still creates a situation where reimbursement is withheld until the provider can prove through the appeals process and medical record documentation that the service was medically and reasonably necessary.
Rather than working through the lengthy appeals process, there is another option for providers to bill units of service that exceed the MUE limit and are medically necessary. CMS has provided guidance that MUEs are to be adjudicated separately against each line on a claim rather than the entire claim. This process is triggered by appending an appropriate modifier to more than one line on a claim reporting the same CPT code. CPT modifiers such as 76 (repeat procedure by same physician), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service) will accomplish this purpose. However, providers should be aware that modifier 59 is the modifier of last resort and should only be used if no other modifier describes the service.
Here is an example of what this might look like on a claim for laboratory services where the MUE=4 and the physician ordered 5 medically necessary electrolyte panels for the same date of service:
300 Laboratory 80051 $100.00 082211 1
300 Laboratory 80051-91 $400.00 082211 4
The Medicare claims processing system looks at the first line and since it does not exceed the MUE, it is processed further for payment consideration. The system then looks at the next line with the same CPT code but reported with modifier 91 and it meets but does not exceed the MUE limit, so it is also processed further for payment consideration.
There is one last point to take into account when a provider exceeds the MUE. CMS considers the denial of services due to exceeding an MUE is a coding denial, not a medical necessity denial. Because of this, a provider should not issue an Advance Beneficiary Notice (ABN) when an MUE may be triggered which means that the provider cannot bill the patient for the excessive units – the denied units of service become a provider liability.