Medically Unlikely Edits
BCBSND edits procedure code units on professional claims, excluding Home Medical Equipment (HME)/Durable Medical Equipment (DME), through MUEs. The number of units for codes that qualify for submission of multiple units may be subject to limits. MUEs will ensure the following elements are valid and medically likely based on the procedure code submitted.
- Unit is based on the code’s unit of measurement
- Multiple units of service reported per code are medically likely
- Multiple units assigned for per date of service (DOS) codes are medically likely. DOS codes are usually indicated by words such as each or per
Note: DME/HME claims will not apply MUE edits in BCBSND edits, however, they will be subject to Payment Integrity MUE editing.
MUE edits are applied to claims in the pre-adjudication phase based on the values posted by CMS. BCBSND reserves the right to apply MUE edits outside of the CMS values when it is deemed clinically appropriate. A listing of the Professional (codes submitted on a CMS-1500 Claim Form) MUEs that differ from the CMS values can be located on the Medically Unlikely Edits Revisions Addendum.
Note: BCBSND does not recognize an MUE value of "0".
Outpatient claims processed under Enhanced Ambulatory Patient Group (EAPG) System will apply MUE edits with a DOS on or after April 1st, 2022. For claims processed on the Hospital Outpatient Fee Schedule (non EAPG) will not apply MUE edits, however, they will be subject to Payment Integrity MUE editing.
Note: Effective April 1st, 2022, Outpatient Claims processing through EAPG, with units billed over the MUE values will result in the rejection of the entire claim line.
For Outpatient EAPG claims, a claim line billed over the CMS MUE value will result in the entire line rejecting. However, if services are rendered in excess of the MUE value and are deemed medically appropriate then the services must be billed as follows:
- Divide the Units of Service (UOS) by the MUE value to indicate the number of claim lines to be billed
- Append appropriate modifier(s) to any additional claim lines
Medicare Adjudication Indicator (MAI) Categories
Description and Guidelines
Description: Procedure codes with a DOS claim line edit based on standard coding frequencies set by CMS and NCCI.
Guidelines: Providers should append the appropriate modifiers to lines for services provided in excess of the MUE when the service is distinct and separately identifiable (e.g., 25, 58, 59, 76, 77, 78 or 91). If a MUE rejection is received on a procedure code with a MAI of 1, providers should review the medical records and submit a claims adjustment to add a valid modifier only when the documentation supports the service was distinct and separately identifiable.
Description: Procedure codes with an absolute DOS edit based on correct coding.
Guidelines: Procedure codes with a MAI of “2” have been rigorously reviewed and vetted within CMS and obtain this MAI designation because the unit of service (UOS) on the same DOS in excess of the MUE value would be considered impossible. Codes with this MAI have limitations created by anatomical code designation, NCCI policy, or based on the code descriptors. Due to this, procedure codes with a MUE MAI of 2 will not be overturned if an appeal is submitted.
Example: Reporting more than one unit of service for CPT 94002 " ventilation assist and management . . . initial day" would be invalid as the code description indications the services is a per day code.
Description: Procedure codes with a per DOS edit based on clinical benchmarks.
Guidelines: Procedure codes billed in excess of the MUE will be rejected. Providers should review the procedure code(s) with the medical records and submit an appeal if the medical record(s) support the service billed and the medical records support a medically reasonable and necessary service.