Knowledge Base Article

Through review of hospital 835 remittances and communication with our clients, MMP, Inc. has become aware of an increasing number of Medicare denials for units exceeding a Medically Unlikely Edit (MUE) limit. MUEs were implemented in 2007 by CMS to reduce paid claim error rates. Per the CMS MUE webpage “An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.” The MUE list is available on the above webpage; it is updated quarterly but CMS considers some MUEs confidential and does not publish these. Remember that MUE and CCI edits apply to both Medicare and Medicaid claims.

We are seeing a large number of MUE denials for drugs. We have also heard from providers concerning recent denials for additional infusion services, such as for CPT codes 96366 (IV infusion, each additional hour) and 96361 (Hydration, each additional hour). Since these MUEs are unpublished, the MUE limits for these CPT/HCPCS codes are not known.

MMP, Inc. encourages our clients to determine if they are having issues with MUE denials. Line items exceeding an MUE limit will deny with a Claim Adjustment Reason Code (CARC) of B5 (Coverage/program guidelines were not met or were exceeded.) Note that CARC B5 is also used for denials involving Correct Coding Initiative (CCI) edits and for inpatient-only procedures billed on an outpatient claim.  Also look for Remittance Advice Remark Code N362 (The number of Days or Units of Service exceeds our acceptable maximum) to identify MUE denials.

If you are having MUE denials, determine if you are indeed trying to bill the appropriate number of units. The MUE limits for drugs are likely based on the manufacturer’s package insert for recommended dosage amount. To address drug MUE denials, providers should:

• ensure that conversion factors in the CDM are correct for the drug HCPCS description,
• verify that charges are being entered correctly,
• determine if there is a medically necessary reason to exceed the recommended dosage, and
• contact your Medicare contractor if you believe an MUE is unreasonable.

Once you verify that the units you are billing are correct and you determine the MUE value (either the MUE limit is published or you are able to determine it by a trial and error process), you can by-pass the MUE by using an appropriate CPT modifier to report the same code on separate lines of a claim. Since each line of a claim is adjudicated separately against the MUE value for the code on that line, no single line should be reported with units that exceed the MUE limit. For example, if an MUE value is 6 and you provided 18 medically necessary units, you should report three lines each with units of 6 and the appropriate CPT modifier on the additional lines. 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. Providers/suppliers should use Modifier 59 only if no other modifier describes the service.

If you receive denials for MUEs, you may appeal the denial. Documentation in the medical record should clearly support the number of units and the medical necessity for the quantity of services. If a drug dosage exceeds the package insert amount, you will want to provide medical literature to support the dosage amount as part of your appeal.

One last point to consider – a number of the drugs that are being denied for exceeding the MUE value are not separately reimbursed by Medicare but are instead “packaged” drugs. Providers likely will not want to put in time and effort to appeal these denials, but MMP, Inc. encourages providers to ensure that for future claims the units billed are accurate and submitted correctly to by-pass the MUE limits when appropriate. This will prevent the submission of any “false” claim information.

For more information on MUEs, see the link on the CMS MUE webpage to MUE FAQs. And although CMS Transmittal 9490 addresses a technical correction it also contains good information on the MUE process.