APMA News - January/February 2025 - 32

coding update
Medically Unlikely Edits
By Andrew Pavelescu, DPM, and Alex Dellinger, DPM, APMA Coding Committee Members
The National Correct Coding Initiative (NCCI) is
a CMS program that consists of coding policies
and edits. Providers report procedures or services
performed on beneficiaries utilizing Healthcare
Common Procedure Coding System (HCPCS)/
Current Procedural Terminology® (CPT®) codes.
These codes are typically submitted on claim
forms to fiscal agents for payment. The NCCI
coding policies are based on coding conventions
defined in the CPT Manual, national and local policies
and edits, and standard practices.
The NCCI publishes medically unlikely edits
(MUEs), used by Medicare Administrative
Contractors (MACs), to reduce improper payments
for Medicare Part B claims. An MUE represents the
maximum units of service that may be reported for
a HCPCS/CPT code at a single encounter. Not all
HCPCS/CPT codes have an MUE. In essence, an
MUE is a type of automated check used to identify
and prevent submission of services that are unlikely
to be medically appropriate based on the circumstances.
These edits are part of a broader effort to
control health-care spending, reduce fraud, and
ensure that claims are consistent with what is medically
appropriate.
Each MUE has a MUE Adjudication Indicator
(MAI), which helps determine how the claim will be
handled (or adjudicated) by the payer if the MUE is
exceeded.
Possible adjudication outcomes are:
* An MAI of " 1 " indicates a claim line edit.
* An MAI of " 2 " indicates an absolute date of service
edit. These are " per day edits based on policy. "
These codes have been reviewed and vetted
within CMS, and exceeding the MUE is considered
impossible because it would be contrary to
statute, regulation, or sub-regulatory guidance.
* An MAI of " 3 " indicates a date-of-service edit.
These are " per day edits based on clinical benchmarks. "
If claim denials based on these edits
are appealed, payers may allow exceeding the
MUE if there is documentation that supports the
medical necessity of exceeding the MUE. This
outcome may require going through the redetermination
process.
Example: A claim may be submitted for a diagnostic
test whose CPT code is assigned an MUE
of two units (meaning that, under normal circumstances,
the test should be performed no more
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JANUARY/FEBRUARY 2025
than twice per encounter), but the claim is submitted
with five units. In this situation, the edits may
detect that the MUE was exceeded, which could
lead to the claim being denied. The MAI for that
particular MUE would determine the final outcome
of the claim.
* If the MAI is " 1, " the claim is denied based on a
claim line edit, given that the units exceeded the
MUE maximum allowed.
* If the MAI is " 2, " that would indicate that the MUE
exceeded the limit based on statute, regulatory
or sub-regulatory guidance, and the claim
is denied. If the MAI is " 3, " the claim is denied
based on a date-of-service edit, given that the
reported units exceeded the maximum per day
MUE allowed.
MUE denials for MUEs with an MAI of " 1 " or " 3 "
may be appealed. Appeals should be submitted to
the payer with documentation that supports the
medical necessity of exceeding the MUE.
An excellent resource to review is the MLN
Matters® Number: MM8853 - Medically Unlikely
Edit (MUE) Program: www.cms.gov/files/
document/revised-modification-medicallyunlikely-edit-mue-program-mm8853.pdf.
Knowing
the MUE/MAI system for the codes
submitted on a regular basis clearly allows practices
to be more prepared and successful. It is
important to review practice data and determine
the 20 CPT codes submitted most frequently, then
concentrate on the MUE and corresponding MAI
for each.

http://www.cms.gov/files/document/revised-modification-medically-unlikely-edit-mue-program-mm8853.pdf http://www.cms.gov/files/document/revised-modification-medically-unlikely-edit-mue-program-mm8853.pdf http://www.cms.gov/files/document/revised-modification-medically-unlikely-edit-mue-program-mm8853.pdf

APMA News - January/February 2025

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