MIR-2007 04AB, April 2007

Medically Unlikely Edits (MUE)(CR5495)

Provider Types Affected
Physicians, suppliers, and providers who submit claims to Medicare contractors (Fiscal Intermediaries (FI), carriers, Part A/B Medicare Administrative Contractors (A/B MAC), DME Medicare Administrative contractors (DME/MAC), and/or regional home health intermediaries (RHHI))

Background
In order to lower the Medicare fee-for-service paid claims error rate, the Centers for Medicare & Medicaid Services (CMS) established units of service edits referred to below as MUEs. The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs.

• An MUE is defined as an edit that tests claim lines for the same beneficiary, Healthcare Common Procedure Code System (HCPCS) code, date of service, and billing provider against a criteria number of units of service.
• For carrier claims, the MUEs will automatically deny or suspend claim line items containing units of service billed in excess of the MUE criteria and for FI claims, the MUEs will return to provider (RTP) claims that contain lines that have units of service that exceed an MUE criteria.

Key Points

• CR5495 announces the upcoming release of the next version of the MUEs, which is version 1.1.
• CR5495 states that Medicare carriers and A/B MACs will deny the entire claim line from non-institutional providers with units of service that exceed MUE criteria and pay the other services on the claims.
• FIs and A/B MACs will RTP claims from institutional providers with units of service that exceed MUE criteria.
• An appeal process will not be allowed for RTP claims as a result of an MUE. Instead, providers should determine why the claim was returned, correct the error, and resubmit the corrected claim.
• Providers may appeal MUE criteria by forwarding a request the carrier or A/B MAC who, if they agree, will forward the appeal to the National Correct Coding Contractor.
• Excess charges due to units of service greater than the MUE may not be billed to the beneficiary (this is a “provider liability”), and this provision can neither be waived nor subject to an Advance Beneficiary Notice (ABN).

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5495) issued to your Medicare carrier, FI, A/B MAC, DME MAC, DMERC, or RHHI. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1202CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier, FI, DME MAC, RHHI, or A/B MAC, at their toll-free number which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5495
Related Change Request (CR) #: 5495
Related CR Release Date: March 9, 2007
Effective Date: April 1, 2007
Related CR Transmittal #: R1202CP
Implementation Date: April 2, 2007

PQRI Information Available
A new CMS Web page dedicated to providing information on the Physician Quality Reporting Initiative (PQRI) is now available.

On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit http://www.cms.hhs.gov/pqri on the CMS Web site.