Medically Unlikely Edits

February 28th, 2009 - Codapedia Editor
Categories:   Coding   Compliance  
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Medicare developed a set of edits that it has instructed carriers, fiscal intermediaries, DME processors, and now Medicare Administrative Contractors (MACs) to follow.  This edits were developed in addition to the National Correct Coding Initiative Edits to keep the payers' claims processing systems from paying for unreasonable, or unikely, services.   CMS's stated goal is to reduce the error rate for Medicare paid claims.

The Medically Unlikely Edits (MUE) contain edits to deny multiple units of a single service provided to the same patient by the same physician on the same day.  CMS published some, but not all, of the edits they put into place. 

According to the Frequently Asked Questions on the CMS web site for the page for MUE, these edits may be overridden by the appropriate use of modifiers, if needed.  The modifier for repeat procedures by the same or different physician or modifier 59 for a distinct procedural service, may be appropriate.  Although CMS didn't say this, one would think that the routine use of these modifiers to override MUE edits would raise flags.

FAQ number 8736 from the CMS website is reproduced below:

 

How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value?

  Answer
 

Since each line of a claim is adjudicated separately against the MUE value for the code on that line, the appropriate use of Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT® modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service.

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