CMS Date of Service Medical Unlikely Edits Implemented for Some HCPCS and CPT Codes

CMS implemented date of service (DOS) medical unlikely edits (MUEs) for some Healthcare Common Procedure Coding System (HCPCS) and CPT codes effective April 1, 2013. CMS is converting some claim line MUEs to DOS MUEs. The total units of service (UOS) from all claim lines for a HCPCS/CPT code with the same DOS will be summed and compared to the MUE value. Claims denied based on DOS MUEs may be appealed using similar processes to claim line MUE denials. CMS does not publish which codes have DOS MUEs. Since all UOS for a HCPCS/CPT code on all claim lines with the same DOS are summed, reporting additional UOS on separate claim lines with a HCPCS/CPT modifier will not result in payment of UOS in excess of the MUE value.

The CMS developed MUEs to reduce the paid claims error rate for Part B claims. A MUE for a HCPCS/CPT code is the maximum UOS that a provider would report under most circumstances for a single beneficiary on a single DOS. For MUEs that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. For MUEs that are adjudicated as DOS edits, UOS in excess of the MUE value may be paid during the appeal process.