Why CMS Do Not Publish All the MUEs

Why CMS Do Not Publish All the MUEs


Each quarter, CMS updates the medically unlikely edit listing with new and updated edits. If the CMS feel that there are new ones to add, it will update them. There is a particular contractor that handles these edits. And you can petition that contractor if you feel that one of the medically unlikely edits is inappropriate and get that reviewed. And if they do review the same and decide to make a change, you would see an update on that. On the other hand, you may also see some edits being taken away.

However, there are also some edits that are just not made public by the CMS. They do not reveal all MUEs all the time. Suppose, if you get return to provider claims or denied claims that have a couple of different reason codes on them, you can take a hint of why it was denied or returned. You may have checked your claims against these edits and notice that it wasn't a part of it, and that in turn will probably be one of these edits that's not actually been made public by the CMS. But mostly, they do tell us about the active edits for each quarter.

The edits are actually aimed at catching fraudulent providers, not billing errors. That is one reason, why sometimes we do not see all of them, if we're checking for billing errors against these edits. These are the kinds of things that - the ones that they make public show. If you have some folks that are out there gaming the system, they know exactly how many of each thing they can bill and are billing the maximum amount, obviously that's not going to be helpful at catching those fraudulent providers. So, hence the reason we don't know about all of them.

At the start of each quarter, CMS will publish that group of MUEs for the quarter. But many of those that are not published are the ones with a unit of service 4 or higher. If there are services that have a medically unlikely edit of 4 or higher, those are the ones that we're typically not seeing. So, for those - if you do have an instance where you're getting hit on one of those from a return to provider or a denial perspective and it's a unit - or it's a service that you're billing more than 4 units of, that's potentially a medically unlikely edit that has not been published. And hopefully, you can take that information going back from your returned claim or your denied claim and have that for the future to add to your edits, so you can take a look at them before they go out.

The medically unlikely edits themselves are unit of service edits or UOS edits. And the unit of service edit is exactly what it sounds like, how many of a single item can you bill on one day? For e.g.19296 which is placement of a radiotherapy after loading expandable catheter into the breast for interstitial radioelement application, following partial mastectomy. So, that's what the code stand for. It includes imaging guidance. And in this instance, the medically unlikely edit tells us that only two are billable per day. This makes sense, just given anatomy and what not that only two are billable per day and that's a typical unit of service edit and that's where these medically unlikely edits surround. They're all around these unit of service edits.

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