August 23, 2011 | | Comments 8
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Bypassing medically unlikely edits (MUE)

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.

Entry Information

Filed Under: OPPS


Debbie Mackaman About the Author:

Debbie is an instructor for HCPro’s Medicare Boot Camp®—Hospital Version. She has over 18 years of experience in the healthcare industry, including both inpatient and outpatient Prospective Payment Systems (IPPS, OPPS) and Critical Access Hospital (CAH) coding and reimbursement issues. She most recently held the position of the Compliance Officer and Director of Health Information Services for a healthcare system.

She consults with hospitals, physicians and other healthcare providers on a wide range of coding and billing issues. She assists in the development of compliance programs, with a focus on high risk areas including RAC topics, documentation improvement, coding and billing audits, and chargemaster maintenance.

She is an active participant with state and national organizations and task forces on coding and payment policies, privacy and continuing education. She is accredited as a Registered Health Information Administrator (RHIA) and a Certified Healthcare Compliance Officer (CHCO). She is a member of the American Health Information Management Association (AHIMA) and is the past president of the Montana Health Information Management Association (MHIMA).

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  1. We have expereinced a fairly large amount of MUE denials for J codes, specifically J1885, J0282 and J0171. We re-verified with the pharmacist that the J code is correct, with the correct dosage being reported. WPS can not tell us what the MUE edit amount is for those codes. We have submitted records on a few of them, with no reply yet. Do you have any other suggestions? If we could get the MUE edits and help educate the physicians on allowable amounts, perhaps ordering practices could change.

  2. I need the same information as Doris Dickey. How do we handle the denied J codes (MUE) other than appeals?
    Thank you

  3. Debbie Mackaman

    After reviewing the list of published CMS MUE limits, unfortunately J-codes are not listed. When codes are not listed it could be that either an MUE does not exist or that one does exist but it is confidential and cannot be released by CMS or its contractors. Based on your question, it appears that you are getting this type of an edit returned from WPS. According to this recent CMS transmittal, as well as past communications, each line on the claim is adjudicated separately so medically necessary services beyond the maximum units of service can be billed on separate lines. For example – J0171 Injection Epinephrine 0.1 mg could be billed on separate lines with the appropriate modifier for each injection of 0.1 mg. CMS has stated that this is an acceptable method to bypass an MUE edit when the services are medically necessary and the documentation can support that. By using this method, the lines should not be denied for an MUE and would not need to be appealed on that basis; however, there may be other coverage or billing issues that may prevent payment.

  4. In my conversation with our MAC(NGS),service rep did not offer any advice to gettting the “J” code paid for the units administered – she indicated we would have to appeal each claim.What modifier could you possibly use for a drug? None of the modifiers (-59,-91 or -76)relate to drugs. Would you suggest the -59 in this case?

  5. What about modifier GD (units of service exceeds medically unlikely edit value and represents reasonable and necessary services)? Is this usable?
    In a Radiation Oncology class two years ago, it was recommended to use this on the second line. One example was the CPT code 77334 if the quantity exceeded 10.
    77334 $1000.00 0823 10
    77334-GD 200.00 0823 02

  6. Debbie Mackaman

    Modifiers are very case specific and would require review of the medical record documentation to be able to provide information on which one would apply in your scenario. Modifier -59 is the modifier of last resort and should only be used if no other modifier defines the scenario. I would suggest reading MLN Matters Article SE0715 for CMS’ guidance on when to apply that modifier. –GD modifier (Units of Service Exceeds Medically Unlikely Edit Value and Represents Reasonable and Necessary Services) was published in the January 2008 OCE and HCPCS data files; however, it has never been implemented and is not a CMS approved modifier at this time.

  7. With your example of allowable 4 units, the one extra unit does not have the modifier and the 4 does. My understanding was that we are suppose to bill the maxable allowed and the modifier is to be on the consecutive lines. Which way is correct? We are having extreme issues with J0885 and since it is confidential I would like to make the correct modifier correction and appeal. Does anyone have additional suggestions to this drug when billing with full medical necessity?

  8. Does any one know what the MUE is for J0171? Has anyone figured out what modifier to use when the quanity if over the allowable limit? We have been having this issue for quite some time now. We have verified with our pharmacy and the quanity is correct for what we are billing. Any suggestions would be helpful.

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