Medically Unlikely Edits (MUEs)

Transmittal 178, Change Request 5402, dated December 8, 2006, is being rescinded and replaced with Transmittal 617. This change request replaces the file format and some of the process and is denying FISS lines; and updates how CMS handles modifier 55. All other material remains the same. CMS developed the MUE program to reduce the paid claims error rate for Medicare claims. As clarification, an MUE is a unit of service (UOS) edit for a HCPCS/CPT code for services that a single provider/supplier rendered to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. Note that the MUE program provides a method to report medically likely UOS in excess of an MUE. Further, all CMS claims processing contractors shall adjudicate MUEs against each line of a claim rather than the entire claim. Thus, if a HCPCS/CPT code is charged on more than one line of a claim by using CPT modifiers, the claims processing system separately adjudicates each line with that code against the MUE. In addition, fiscal intermediaries (FIs), carriers and Medicare Administrative Contractors (MACs) processing claims shall deny the entire claim line if the units of service on the claim line exceed the MUE for the HCPCS/CPT code on the claim line. Since claim lines are denied, the denial may be appealed. Since each line of a claim is adjudicated separately against the MUE of the code on that line, the appropriate use of CPT modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service), will accomplish this purpose. Providers/suppliers should use Modifier 59 only if no other modifier describes the service. Note that, at the onset of the MUE program, all MUE values were confidential, and for use only by CMS and CMS contractors. Since October 1, 2008, CMS has published most MUE values at the start of each calendar quarter. However, some MUE values are not published and continue to be confidential information for use by CMS and CMS contractors only. The confidential MUE values shall not be shared with providers/suppliers or other parties outside the CMS contractor’s organization. In the MUE files each HCPCS code has an associated “Publication Indicator”. A Publication Indicator of “0” indicates that the MUE value for that code is confidential, is not in the CMS official publication of the MUE values, and should not be shared with providers/suppliers or other parties outside the CMS contractor’s organization. A Publication Indicator of “1” indicates that the MUE value for that code is published and may be shared with other parties. Finally, a denial of services due to an MUE is a coding denial, not a medical necessity denial. A provider/supplier shall not issue an Advance Beneficiary Notice of Noncoverage (ABN) in connection with services denied due to an MUE and cannot bill the beneficiary for units of service denied based on an MUE. The denied units of service shall be a provider/supplier liability.