Medically Unlikely Edit

A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day. Claim edits compare different values on medical claim to a set of defined criteria to check for irregularities, often in an automated claims processing system. MUE are designed to limit fraud and/or coding errors. They represent an upper limit that unquestionably requires further documentation to support. The ideal MUE is the maximum unit of service for a code on the majority of medical claims.^[1] MUE is part of the National Correct Coding Initiative (NCCI) to address coding methodologies. The NCCI policies are based on coding conventions by nationally recognized organizations and are updated annually or quarterly. ^[2]

History

Medically Unlikely Edits began in January 2007 ^[3] they are generally based on biological considerations, like number of limbs or organs. They adjudicate on units billed per line of service.^[4] The same code billed on different lines for the same date of service are subject to duplicate adjudication edits where CPT Modifiers like 59, 76 and 77 may impact the payment.^[4][5] The edits were not publicly released until 2009, with some of them remaining confidential out of concern for abuse^[6] .^[7] MUE are not intended to be utilization guidelines. Units less than listed may be inappropriate.^[8]

It is difficult to establish to what extent private payers are using NCCI edits.^[9] Other than published CMS edits, there are no nationally recognized code edits, although there have been proposals to create some.^[10] A 2005 study found that private payers were applying “CPT codes, guidelines and conventions”, “CMS payment rules”, “National Correct Coding Initiative”, and “Payer-specific proprietary edits” to claim, of these about 25% were “Payer-specific proprietary edits” ^[11]

References

1. CMS (September 25, 2009). "What is a Medically Unlikely Edit (MUE)?" (web). Q&A. Centers for Medicare and Medicaid Services. Retrieved January 21, 2010.
2. CMS (October 1, 2009). "National Correct Coding Initiatives Edits; Overview" (web). CMS Rule. Centers for Medicare and Medicaid Services. Retrieved January 21, 2010.
3. CMS (January 1, 2010). "Medically Unlikely Edits" (Web). CMS Rule. Centers for Medicare and Medicaid Services. Retrieved January 21, 2010.
4. ACRO (2009). "Putting it into Perspective – Medically Unlikely Edits" (PDF). Article. American College of Radiation Oncology. Retrieved January 21, 2010.
5. CMS (September 25, 2009). "How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value?" (web). Q&A. Centers for Medicare and Medicaid Services. Retrieved January 21, 2010.
6. Lansey, Debra (February 2009). "Follow the changes to Medicare coding edits for early 2009" (web). Article. American College of Physicians. Retrieved January 21, 2010.
7. HCPro (October 7, 2008). "Busy week: OIG Work Plan, CMS' MUE list available" (web). Article. HCPro. Retrieved January 21, 2010.
8. CMS (September 25, 2009). "Has CMS published the Medically Unlikely Edit (MUE) values for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes?" (web). Q&A. Centers for Medicare and Medicaid Services. Retrieved January 21, 2010.
9. ACSO (2008). "Do private payers use the NCCI edits established by CMS?" (web). Journal of Oncology Practice, Vol 4, No 3 (May), 2008: pp. 116-117. American Society of Clinical Oncology. Retrieved January 21, 2010.
10. AMA (June 2005). "FEASIBILITY STUDY ON THE DEVELOPMENT OF CPT COMPLIANT CODE EDITS" (pdf). Report. American Medical Association. Retrieved January 21, 2010.
11. NHXS (2005). "What private payers do to your claim: repricing and claims editing" (PDF). review of report by National Health Exchange Services (NHXS). American Medical Association. Retrieved January 21, 2010.