CMS has developed “Medically Unlikely Edits” to limit the maximum units of service a provider can report under most circumstances for a single beneficiary on a single date of service.
As announced in MLN SE1422, titled “Medically Unlikely Edits (MUE) and Bilateral Procedures,” for dates of service starting July 1, 2014, CMS is converting most MUEs into per day edits, with the MUE Adjudication Indicator (MAI) value indicating the type of and basis for the MUE.
CMS has defined three MAI values:
MAI of 1. MUE is based on a line edit and medically appropriate units of service in excess of the MUE. May be reported on a separate line with an appropriate modifier, and each line will process for payment.
MAI of 2. MUE is based on regulation or sub regulatory instructions.
MAI of 3. MUE is based on clinical information such as billing patterns, prescribing instructions, or other information, and exceptions beyond the MUE would be rare.
For example, IHCs: G0461 is limited to 9 units per date of service, whereas G0462 is limited to 60, with an MAI of 3.
Billers should be aware of these MUE edits and upon denial, review claim submissions and either request to reopen the claim for processing, or appeal with documentation to support excess units for medical necessity.
Ann Lambrix is the Executive Client Administrator at Vachette Business Services and Stark Medical Auditing, your go-to source for industry updates and changes. Visit our websites at vachettepathology.com and starkmedicalauditing.com, or call us at 517.486.4262.