Medically Unlikely Edits for May 2007

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 Medically Unlikely Edits (MUEs). The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs

Key Points

• The upcoming release of the next version of the MUEs, which is version 1.1.
• Medicare carriers and A/B MACs will deny the entire claim line from non-institutional providers with units of service that exceed MUE criteria and pay the other services on the claims.
• FIs and A/B MACs will RTP claims from institutional providers with units of service that exceed MUE criteria.
• An appeal process will not be allowed for RTPÕed claims as a result of an MUE. Instead, providers should determine why the claim was returned, correct the error, and resubmit the corrected claim.
• Providers may appeal MUE criteria by forwarding a request the carrier or A/B MAC who, if they agree, will forward the appeal to the National Correct Coding Contractor.
• Excess charges due to units of service greater than the MUE may not be billed to the beneficiary (this is a Ã’provider liabilityÓ), and this provision can neither be waived nor subject to an Advanced Beneficiary Notice (ABN).