by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
January 7th, 2020
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are not to be used as utilization guidelines. CMS states; "CMS is concerned that providers will incorrectly interpret MUE values as utilization guidelines. MUE values do NOT represent units of service that may be reported without concern about medical review. Providers should continue to only report services that are medically reasonable and necessary."
What are the MAI indicators?
Each MUE is assigned a Medicare Adjudication Indicator (MAI), further specifying how MACS look at MUE's. MUE's and MAI's are used by providers, suppliers, and MACS in all settings. these are the most common and published MAI's. There are MUE's with a value of less than 1 and a value of 4 or more that are not published due to concerns from CMS about fraud and abuse.
MAI 1 - adjudicated as a claim line edit
MAI 2 - per day edits based on policy (Impossible to bill excess MUE's)
MAI 3 - per day edits based on clinical benchmarks (UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary)
MUEs are automatically denied or deemed an "auto-deny edit"
Because they are an auto-deny edit, it is important to be aware of the MAI's assigned to each MUE. These types of denials should all be appealed and sent back for reconsideration if denied incorrectly. ASC Providers (specialty Code 49) cannot use modifier 50 (Bilateral procedure), therefore the MUE with an MAI of 1 is automatically doubled by the MAC.
Incorrect usage of MUE's will be denied as a coding denial, not a clinical or medically necessary denial.
Claim Remark Codes
On your EOB or remittance advice, to identify claims that fail the MUE edit claim, remark codes N362 and MA01 will be used.
Inquiries about the MUE program, including those related to NCCI (PTP, MUE, and Add-On) edits, should be sent to NCCIPTPMUE@cms.hhs.gov. Inquiries about a specific claim should be addressed to the appropriate MAC.
Appeals and Reconsideration
If a national healthcare organization, provider, or other party wants to submit a request for reconsideration of an MUE value, the procedure described in the Frequently Asked Questions (FAQs) should be followed. See the weblink below. Such requests should be addressed to:
National Correct Coding Initiative
P.O. Box 368
Pittsboro, IN 46167
Fax #: 317-571-1745