Introduction
Most healthcare providers are aware of the Medicare edits that can make it more difficult to get paid on claims. However, there’s a type of edit that’s not as well-known: MUEs, or Medicare Unique Edit Values. These codes indicate whether or not a particular service is UCR-related, meaning that you can’t use the same code twice in one day (unless you have an exception). If you do use such a code more than once, it could result in your claim being denied. Here’s everything you need to know about MUEs and how they affect your practice:
What Are MUEs?
MUEs are a set of internal edits used by Medicare to ensure that providers are not billing for services that are not medically necessary. They’re not for the patient, but for Medicare. In fact, many MUEs do nothing to improve healthcare quality or patient outcomes—they’re simply ways for Medicare to prevent fraud and misuse of funds by preventing providers from charging them for services they don’t think should be covered or reimbursed.
How do MUEs work?
MUEs check the documentation associated with each claim in order to detect when something seems out of place. For example, if your office has never seen one patient before who has chronic kidney disease (CKD), then you wouldn’t expect them ever again (unless they moved). If someone suddenly shows up with CKD after having never been treated by your practice before, that’s probably suspicious behavior on their part: maybe they’re trying to get free care! Or maybe they live in another town and just discovered how great it is where you practice so now they want all their relatives sent here too…or maybe this was their lifelong dream but never had an excuse until now; either way something isn’t right are quality outcomes in healthcare
What are quality outcomes in healthcare
t and need further investigation before processing any claims associated with these patients’ names again.”
MUEs Are UCR-Related
The MUE program is related to the UCR, which stands for “Utilization Control Review.” The UCR is a way Medicare reviews claims to ensure that the right codes are being used for the right services. It’s also one of the ways in which Medicare plans on saving money in 2019.
While it’s true that the MUE program will be used as a way to reduce costs and make sure providers aren’t falsifying or abusing their billing privileges, you should know that when your patients receive care from you, it will still count toward their annual out-of-pocket spending limits.
Why Should You Care About MUEs?
MUEs are used to limit the frequency of a CPT code can be used. In other words, if you have a service that is placed on an MUE, it means you cannot use that particular service more than once per day. What does this mean for your practice? It means that if you’re trying to bill for something like “wavefront analysis” (which is one of many services on an MUE), your patient can’t get this procedure done more than once per day.
This is important because some codes may sound like they’re meant for easy billing but actually require careful attention when submitting claims to avoid denials or audit notices from Medicare/Medicaid or private payers alike.
CPT codes with MUE values of 2 or higher don’t have any wiggle room to be used more than once per day.
As you’ve probably noticed, there’s a lot of information to digest when it comes to MUEs. However, you may be surprised by how many CPT codes are subject to MUE restrictions and how they’re used in the billing process.
By now you know that MUEs are important because they can result in denials if used incorrectly or more frequently than allowed. But did you know that not all denials stem from incorrect use of a code?
In fact, only 30% of claims submitted with an incorrect modifier get denied because of the modifier error. The remaining 70% are actually denied because of an unpaid claim or coding error—which means these errors have nothing to do with modifiers at all!
What Happens If You Bill More Than the MUE?
You will be denied if you bill more than the MUE.
The MUE value is based on the type of service, not the individual patient. It’s an average across all inpatient services. The MUE value increases when there’s a higher cost associated with a service due to factors like:
● A complicated diagnosis; for example, multiple comorbidities or complications
● Lengthy hospitalization; for example, stays over 4 days
● High-tech equipment; for example, MRI imaging machines or CT scanners
Denials Due to MUEs vs. Denials Due to Other Reasons
If your claim has been denied by the insurance company, it’s important to identify why. Was it because of:
● The MUE that was used?
● An excessive use of services?
● A coding error?
● An insurance company error?
There are a few variations in denials that can help you determine whether or not the denial was due to an MUE.
There are a few variations in denials that can help you determine whether or not the denial was due to an MUE.
● For example, if your claim is denied at two different facilities and they both have the same CPT code but different MUE values, this indicates that there may be an issue with how you reported your diagnosis and procedure codes. This could also indicate a problem with how the facility coded its information. It’s best to contact both providers and find out what happened with your claims before sending more claims for that service code.
● If you get rejected for multiple codes (CPT) with different modifiers but all have the same MUE, there may be some sort of misunderstanding about what services were performed on what day or at what time during each patient encounter. If this is happening frequently with multiple services across several months or years of documentation, then it may indicate something wrong in how you’re presenting your documentation or coding practices are not up-to-date enough for Medicare standards
Excessive Use of Services Not Reimbursed Denial Codes Related to MUEs
MUEs are a new way for Medicare to minimize fraud and abuse, and the Centers for Medicare & Medicaid Services (CMS) has established some specific rules about what is considered excessive.
You can check your MUE status by submitting a “Medicare Enrollment Data Request” form here.
It’s important that you understand what MUEs mean because sometimes they can prevent your claim from being paid by Medicare when you submit an appeal or reconsideration request. If you don’t know what MUE means, consider reading this article: What Are Excessive Use of Medical Services Denial Codes?
A high-level summary of how this works: If your medical treatment has been identified as being used in ways that are not medically necessary for the condition being treated (or is not likely to improve your health), then it may be denied by CMS due to an “Excessive Utilization” code related to MUEs on their part. There are several different types of these codes which depend on where they occur in relation to providers’ offices/hospitals/clinics etc., such as outpatient or ambulatory surgery centers (ASC). Most commonly though doctors’ offices will have these denials applied against them when submitting numbers through ICD-10 coding systems at point-of-service locations (POS).
16 and 22 Denials Don’t Mean an Edit Was Used Up, Though
You may believe that if your edit is denied, it’s because the number of edits allowed for a service has been used up. This isn’t true. The edits you see on your claims are not used up by denials, but rather by the number of bills submitted within one calendar year.
While most codes will have 16 and 22 edits (16 means “you can submit two bills per patient per calendar year,” while 22 means “you can submit four bills per patient per calendar year), there are some exceptions: emergency services (inpatient and outpatient) have a 12 edit for both inpatient and outpatient; some inpatient diagnostic radiology codes also have an 18 edit, and certain surgical procedure codes have only 20 edits available to them each year.
How Do I Know I Need to Appeal a Denial Due to an MUE?
If you know what the Medicare edits are for the services you provide and when you need to appeal an excessive use denial due to an edit, then you can avoid denials. If a patient receives a service that is covered by Medicare but requires documentation of medical necessity in order for it to be considered medically necessary, then this is known as a Medicare edit. A provider may not want to follow up on this because they do not want to put in more work than they already have. However, if there is no documentation or insufficient documentation of how many times that same service was performed during the year before or after that date (as stated above), then Medicare will determine whether or not the provider had just cause for providing those services so often.
For example The MUEs would be something like blood transfusions (more than three per year).
Know what the Medicare edits are for the services you provide and when you need to appeal an excessive use denial due to an edit.
A Medicare edit is a condition that Medicare will identify as an issue with your claim. These can be minor and not affect the overall payment or they can be major, resulting in a denial of some or all of your claim.
If you receive an excessive use denial due to one of these edits, you have 90 days from the date of service to appeal it. It’s important for you to know what MUEs are so that when you get an unexpected denial on one of your claims, you’ll know what caused it and what needs to happen next.
Conclusion
The most important thing to remember is that the Medicare edits are designed to help you avoid making mistakes that result in a denial of your claim. If you are still having problems with denials due to MUEs, reach out to our team and we will be happy to help!
