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Date of Service Edits Expanded to Enforce Medically Unlikely Edits' Unit of Service Designation

The Centers for Medicare and Medicaid Services (CMS) is enforcing Medically Unlikely Edits (MUEs) by expanding screening edits that will deny claims for bilateral billing.

MUEs were implemented in 2007 by CMS to reduce the paid claims error rate for Part B services.  Per CMS, an MUE is the ‘maximum unit(s) of service that a provider would report under most circumstances for a single beneficiary on a single date of service.’  There is not an MUE for every CPT/HCPCS code.  While the list of published MUEs can be found at the following link:  http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html, it is important to note that some are not published as they are considered for CMS/CMS Contractors’ use only.

CMS contends that the need to implement additional screening edits was based on claims data specific to MUE levels which confirmed a pattern of inappropriate billing where multiple line items of a CPT code would allow the claim to bypass the MUEs.  Consequently, CMS is converting most MUEs into per-day edits to eliminate the chance of the subsequent unit(s) of the CPT code to be paid.

For example, to bill a bilateral procedure to CMS when the CPT code’s description doesn’t include the term ‘bilateral,’ the CPT code is reported as a single line item appended with modifier 50 (Bilateral procedure).  If the code is prohibited from bilateral billing due to the MUEs, CMS denies all claims with that code and modifier 50 combination.  However, there are other formats for billing a procedure bilaterally, such as reporting the CPT code as two line items and/or using the RT and LT modifiers.  With these other formats, the edit looking for the CPT and modifier 50-combination is bypassed, allowing consideration for payment of both units of the code.  To prevent this, a ‘once per day’ edit will now cover those procedure codes making them payable only once per day regardless of the method used to report them as bilaterally-performed.  Denials for units of service in excess of the MUE value that were adjudicated as date of service edits may be reconsidered for payment during the appeal process.

Providers do have the right to request the review of MUE values by the National Correct Coding Initiative if it is felt that a value needs to be modified.  Updates to the MUE table are posted on a quarterly basis.  Additional information can be found at:  http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

APS Medical Billing reports bilaterally-performed procedures that do not have their own bilateral CPT codes in accordance with each carrier’s required method for line items, units of service and modifiers. 

If you have any questions, please contact your Practice Manager.

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