See to it that you are not letting MUEs play havoc on your practice's coding and reimbursement by keeping these things in mind.
You should not ignore medically unlikely edits; and even if you have to do it, do it at your own risk.
Medically unlikely edits often confuse even the most seasoned coders. See to it that you are not letting MUEs play havoc on your practice's coding and reimbursement by keeping these things in mind.
Know what MUEs are
Any practice that files a claim with Medicare should be aware of what MUEs are and how they function. MUEs were developed by CMS to reduce paid claims error rates in the Medicare program. One should not let every denial go because the insurance company said it was an MUE. The medically unlikely list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay.
The agency updates the MUE list every quarter but it does not publish all MUEs, especially those with values of four or higher.
Don't use ABNs to transfer responsibility for payment to the beneficiary
Remember that you cannot use ABNs to transfer responsibility for payment to the beneficiary. CMS makes this rule very clear in its FAQs: A provider or supplier may not issue an ABN for units of service in excess of an MUE.
Can you override an audit?
According to CMS, MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have; as such you are not required to override them often. However you can override an MUE when your doctor performs and documents a medically necessary number of services that go past the limit.
You need to check your payer's reporting preference: HCPCS offers modifier GD, however there's little information available on the correct use of this modifier. According to CMS, modifiers 76 and 77 are among your options to override an MUE as are the anatomical modifiers, such as RT. You may also use modifier 59 but you need to use this only if no other modifier is appropriate.
You can appeal an MUE denial
If you get a claim denial owing to MUEs, you can appeal. You can appeal the claims and you can address queries regarding the rationale for an MUE.
Tip: Inspect your explanation of benefits (EOBs) to look for remark code N362, which represents “the number of days or units of service exceeds our acceptable maximum" and may mean your claim has fallen afoul of the medically unlikely edits.
For more tips on mutually unlikely edits, sign up for a one-stop medical coding guide like Supercoder.
Medically unlikely edits often confuse even the most seasoned coders. See to it that you are not letting MUEs play havoc on your practice's coding and reimbursement by keeping these things in mind.
Know what MUEs are
Any practice that files a claim with Medicare should be aware of what MUEs are and how they function. MUEs were developed by CMS to reduce paid claims error rates in the Medicare program. One should not let every denial go because the insurance company said it was an MUE. The medically unlikely list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay.
The agency updates the MUE list every quarter but it does not publish all MUEs, especially those with values of four or higher.
Don't use ABNs to transfer responsibility for payment to the beneficiary
Remember that you cannot use ABNs to transfer responsibility for payment to the beneficiary. CMS makes this rule very clear in its FAQs: A provider or supplier may not issue an ABN for units of service in excess of an MUE.
Can you override an audit?
According to CMS, MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have; as such you are not required to override them often. However you can override an MUE when your doctor performs and documents a medically necessary number of services that go past the limit.
You need to check your payer's reporting preference: HCPCS offers modifier GD, however there's little information available on the correct use of this modifier. According to CMS, modifiers 76 and 77 are among your options to override an MUE as are the anatomical modifiers, such as RT. You may also use modifier 59 but you need to use this only if no other modifier is appropriate.
You can appeal an MUE denial
If you get a claim denial owing to MUEs, you can appeal. You can appeal the claims and you can address queries regarding the rationale for an MUE.
Tip: Inspect your explanation of benefits (EOBs) to look for remark code N362, which represents “the number of days or units of service exceeds our acceptable maximum" and may mean your claim has fallen afoul of the medically unlikely edits.
For more tips on mutually unlikely edits, sign up for a one-stop medical coding guide like Supercoder.
