Medically unlikely edits (MUEs), formally known as medically unbelievable edits, took effect with the Centers for Medicare & Medicaid Services (CMS) on January 2, 2007. The function of MUEs is to detect and deny unlikely CMS claims on a pre-payment basis with the intention of improving Medicare’s payment process.
MUEs are unit of service edits that are based on anatomic descriptions, CPT code descriptions, CPT coding instructions, and medical reasonableness. These edits will test claims on the same beneficiary, Healthcare Common Procedure Code System, date of service, and provider against a standard number of units of service. Examples of some edits are:
- The injection(s), single or multiple trigger point(s), three or more muscle(s) would be set at one;
- The first hour of an infusion would be set at one; and
- Medical reasonableness would be set to the maximum number of a service that could be performed on a patient in a day.
MUEs were developed to help curb the costs from fee-for-service claims paid in error. The difference between National Correct Coding Initiative edits and MUEs is that the latter cannot be overridden by a modifier. An example of the reasoning behind MUEs is that there would never be an instance where the provider would have to aspirate three knees. The physician may not bill the patient or have the patient sign an advance beneficiary notice for the service.
Both CMS carriers and practices can be affected by the high cost of incorrect billing. CMS has paid out millions of payments for incorrect services. A practice can be affected by having to resubmit a claim or return an overpayment. It can cost $10 per claim to submit it correctly the first time, but having to submit a corrected bill increase the cost to $15 or $20 a claim. Imagine that a practice incorrectly bills 500 claims a year—the practice could lose $2,500 to $5,000 annually on paperwork alone.
Having your coding and billing staff review all claims before submission could greatly decrease some of your office expenses.
More information concerning MUEs is available at www.cms.hhs.gov/MLNMattersArticles.
If you have any questions about MUEs, contact Melesia Tillman, CPC, CCP, at (404) 633-3777.
