Medically Unlikely Edits (MUEs) Revisited


The MUEs or Medically Unlikely Edits were developed in 2007 - to reduce paid claims error rates in the Medicare program. Basically, it's a piece of the Medicare program from CMS, and 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. Although, all HCPCS/CPT codes do not have an MUE.

Black Box Edits
The first edits was implemented on January of 2007, but the edits themselves weren't made public. Years ago - there were set edits called the “black box” edits. The industry on the provider side weren't terribly thrilled with these edits mainly because black box edits were just that— in the black box. No one could actually see them. So, for the first year and ten months or so, no one knew what the medically unlikely edits were and wouldn't know what we've been hit by until we got either the “return to provider” or the denial depending on which claims processing system you're administrative contractor uses. For instance, if it's a surgery that's performed on an elbow, we have only two elbows, so the likelihood of having a particular procedure on more than two elbows in one day is medically unlikely. Therefore, the edit value for that particular procedure would probably be set at 2. So that's really what these edits are. They're the kinds of thing that are truly medically unlikely to happen. It doesn't mean that they don't ever happen. And some of them are very cut-and-dry like the elbow example or some of the others that we'll take a look at.

Others are not so cut-and-dry and are kinds of things that really can happen more frequently than the program allows. So, those are the instances where you'll want to use the modifiers to get past those edits.

Let’s take a quick look at why have these things been put in place? And what does the Office of Inspector General tells us? The OIG tell us what they're looking at and what kinds of problems they're seeing. So, the Office of Inspector General is just a wealth of information to us as providers in the provider world to make sure that we are watching what they're doing and thereby taking that and using it within our own facilities or our own practices to make sure we are not making those same mistakes.

Example from OIG Audits
Some claim errors are not caught mainly because only computers really touch the claims upfront. There are some that are looked at by people before they're processed. But the majority of them are not, especially in today's HIPAA compliant world of electronic transaction. So, these types of errors are just not caught upfront. They really need the computer program to go ahead and help catch these errors for us. For example, one provider billed a quantity of 780 units of service when performing only one. And as you might recognize, 780 is the diagnosis code. They accidentally entered the diagnosis code in the units of service field. And in this case, the carrier paid $54,594 when it should have only paid $70. So, a simple error could have been caught upfront especially if this is the type of procedure that you could only do one of on a certain day.

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