Pediatric Coding Alert

Ignore the MUEs and expect a claim rejection.

If you receive CCI-based denials from Medicaid but can't find the edits in the CCI spreadsheet, one possibility is that you're running up against medically unlikely edits (MUEs). The edits, which are designed to prevent overpayments caused by gross billing errors, are usually a result of clerical or billing systems' mistakes.

Get to know what MUEs are and how they'll affect your Medicaid pay as your pediatric practice enters the new year.

Myth 1: MUE Edits Don't Affect Your Practice

Some practices feel that they don't need to worry about MUEs.

Reality: While you shouldn't stress too much, any practice filing a claim with Medicaid should know what MUEs are and how they work.

The MUE list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay, says Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, president of ComplyCode in Binghamton, N.Y. "The first edits were implemented in January 2007, although the edits themselves became public in October 2008," she adds.

Some MUEs deal with anatomical impossibilities while others automatically limit the number of units of service you can bill for a service in any 24-hour period. Still others limit codes according to CMS policy. The MUE list differs from standard CCI edits in that it does not include code pairs. Instead, it lists specific CPT or HCPCS codes, followed by the number of units that CMS will pay.

For example: The MUEs allow you to report only one unit of 81007 (Urinalysis; bacteriuria screen, except by culture or dipstick). You can, however, report two units of 81005 (Urinalysis; qualitative or semiquantitative, except immunoassays).

Anatomical example: The MUEs would deny a claim for acircumcision (such as 54150, Circumcision, using clamp or other device with regional dorsal penile or ring block) for a female patient.

Unit of service example: The edits also limit the claims for 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant.) to a single unit per calendar day. This makes sense because 99460 is a "per day" code.

Myth 2: You Can Never Override an MUE

CMS states that MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have, so you shouldn't need to override them often. But you can override an MUE when your physician performs and documents a medically necessary number of services that exceed the limit. Check your payer's reporting preference.

How it works: HCPCS offers modifier GD (Units of service exceeds medically unlikely edit value and represents reasonable and necessary services). But there is littleinformation available on proper use of this modifier.

A CMS FAQ states that "since each line of a claim is adjudicated separately against the MUE value for the code on that line, the appropriate use of Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value."

CMS notes that modifiers 76 (Repeat procedure by same physician) and 77 (Repeat procedure by another physician) are among your options, as are the anatomical modifiers, such as RT (Right side). You may also use modifier 59 (Distinct procedural service), but Harrington cautions you to use this only if no other modifier is appropriate.

You also may need to supply documentation showing medical necessity for the additional units.

Myth 3: You Can't Appeal an MUE Denial

If your practice receives a denial based on an MUE, you may think that you cannot appeal that denial.

Reality: If you receive a claim denial due to MUEs, you can appeal. First, determine the reason for the denial, Harrington says. If you find a coding error -- such as the wrong number of units entered in the units box -- submit a corrected claim. If you don't find a coding or billing error, decide if you have a legitimate reason to appeal. If you believe there is medical necessity for the services over and above the allowable under the MUE, you should file an initial appeal with your Medicaid carrier.