Medically Unlikely Edits (MUEs)

Provider Types Affected
Physicians, suppliers, and providers who bill Medicare Fiscal Intermediaries (FIs), carriers, Part A/B Medicare Administrative Contractors (A/B MACs), Durable Medical Equipment Regional Carriers (DMERCs), DME Medicare Administrative contractors (DME/MACs), and/or Regional Home Health Intermediaries (RHHIs).

Background
In order to lower the Medicare fee-for-service paid claims error rate, the Centers for Medicare & Medicaid Services (CMS) established units of service edits referred to below as MUEs. The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs.

• An MUE is defined as an edit that tests claim lines for the same beneficiary, Health Care Common Procedure Code System (HCPCS) code, date of service, and billing provider against a criteria number of units of service.



• The MUEs will auto-deny claim line items containing units of service billed in excess of the MUE criteria or Return to Provider (RTP) claims that contain lines that have units of service that exceed an MUE criteria.

Key Points

• CR5402 states that Medicare contractors will deny the claim line or RTP claims with units of service that exceed MUE criteria and pay the other services on the claim as part of initial claims processing activities.



• The MUEs that will be implemented by this notice are based on anatomic considerations. CMS believes that most MUEs based on anatomic considerations are not controversial, but CMS will allow and require an appeals process for those claim line items that are denied as a result of an MUE edit.



• An appeals process will not be allowed or required for claims that are RTP’ed as a result of an MUE edit. Instead, providers should resubmit corrected claims.



• This set of MUEs that is based on anatomical considerations addresses approximately 2,800 codes.



• Excess charges due to units of service greater than the MUE may not be billed to the beneficiary (this is a "provider liability"), and this provision can neither be waived nor subject to an Advanced Beneficiary Notice (ABN).

Additional Information
For complete details regarding CR 5402 please see the official instruction issued to your Medicare FI, Carrier or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R178PI.pdf on the CMS website.

If you have any questions, please contact your state's Provider Contact Center.

MLN Matters MM5402