Navigating MUEs

November 3, 2016

As with most CMS initiatives, it can be difficult to keep pace with the constantly evolving list of medically unlikely edits, especially when considering CMS and other carriers reserve the right to maintain a list of unpublished MUEs that providers and their billers likely won’t know about until they receive a denial.

We were first gifted with these edits when CMS implemented an unpublished MUE list in 2007 with hopes of reducing the error rate of paid claims. Fortunately, the agency decided to begin publicly publishing most MUEs in October 2008, and now updates the list quarterly.

mue-tableIn an attempt to highlight the constantly evolving nature of MUEs, we’ve identified changes to the maximum number of allowed units for some of the most popular pathology codes that occurred between the list published by CMS in July 2015 and the most recent one released in October 2016.

It’s worth reiterating that CMS and other carriers reserve the right to create unpublished MUEs, which means CMS’s published list is really more of a national guideline than a hard and fast rule.

However, an MUEs existence doesn’t prevent you from appealing to potentially receive full payment for all services provided. We work closely with our clients and their billers to make sure billers are appealing MUE denials and that our clients are getting paid on those appeals. But just because a denial is appealed doesn’t necessarily mean you’re going to get paid, especially if the physician’s documentation does not clearly substantiate the necessity of the number of units performed.

We have encountered some billers who just want to just slap on a 59 modifier to override the edit, but we’re finding more and more that these MUE edits are often not overridden with a 59 edit. You must support those numbers with sufficient documentation if they exceed the limit.

We’ve also seen billers who change the number of units to get around an MUE. Their argument is that the carrier will deny 100 percent of the charges otherwise, so they attempt to get paid on the maximum number of allowed units rather than none. That’s a major red flag in terms of compliance that could create headaches down the road later if you’re audited.

While we know many billers don’t want to dedicate the time and resources necessary for an appeal, they need to understand they must bill only what was performed. And if the carrier denies it, they have to go through the appeal process. It’s best to get a handle on that process now if you haven’t already so that you’re not left scrambling down the line.

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