Claim Processing Changes for MUE Edits

on Thursday, 10 June 2010. All News Items

Some of MMP, Inc.’s clients have reported to us that Medicare has changed how they are handling line items that exceed the MUE limit.  Previously, claims were returned to the provider (RTP’d) indicating the particular line item(s) that exceeded the limit.  This allowed the provider to verify the units and adjust the claim appropriately.  The proper way to submit medically necessary services that exceed the MUE limit is to list the service on one line with a quantity that equals the MUE limit and then submit the rest of the services on additional lines (each line quantity up to the MUE limit) with an applicable modifier (such as modifier 59) to bypass the MUE edit.  

Medicare is now denying line items that exceed the MUE limit, instead of RTP’ing the claim.  This means the provider will have to appeal the claim in order to receive appropriate reimbursement for services exceeding the MUE limit.  The best course of action is to submit line items that exceed the MUE limits appropriately on the initial claim.  This can be accomplished by having front-end edits in place to halt claims with services exceeding the MUE limits.  However, this solution is compromised because CMS does not publish all MUE limits.  Certain MUEs are confidential and not available to providers or vendors.  For these services, it will be a trial and error process to determine acceptable MUE limits.  The published MUE list can be viewed on the CMS website at CMS MUE Edits Page.

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