medically unlikely edit (MUE) and Key Medicare Benefits for Men’s Health

Do you know MUE?

Working in medical billing is like being in a bowl of alphabet soup. 

One of the probably less common acronyms is MUE:  Medically Unlikely Edit.

Read below to find out what an MUE is, and why you should care.

what is a medically unlikely edit A medically unlikely edit (MUE) is an automated claim processing edit that compares the number of units submitted for a procedure code against the designated maximum units that are typically reported for that code on the vast majority of appropriately reported claims.

MUE The edit is applied to services billed by a single provider/supplier to a single beneficiary on the same date of service.

Automated claim processing edit

The MUE program was developed by CMS in an effort to reduce the paid claims error rate for Medicare claims that result from various circumstances such as:

• clerical entries

• incorrect coding based on:

o   anatomic considerations

o   procedure code descriptors

o   procedure coding instructions

o   established CMS policies

o   nature of a service/procedure

o   unlikely clinical treatment

MUE CMS does not publish MUE values for some codes. Some MUE values are confidential and may not be published.

CMS fiscal intermediaries 

CMS fiscal intermediaries and Part A/Part B Medicare administrative contractors (A/B MACs) process claims with the fiscal intermediary shared system (FISS).  

They adjudicate MUEs against each line of a claim rather than the entire claim. If a procedure code is reported more than once, each line with that code is separately adjudicated against the MUE. They will deny the entire claim line if the unit of service (UOS) on the claim line exceeds the MUE value for the procedure code listed on the claim line.

MUE For Example CPT Code 77300 is submitted on one service line for 11 units, if the MUE is 10, then all 11 are denied, instead of a just denying the one unit over the limit.

MUe value modifiersWhen there is a need to report medically reasonable and necessary units of service in excess of an MUE value modifiers can be used 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.

modifiersThe modifiers noted below will accomplish this purpose.

• 76 -- Repeat procedure by same physician

• 77 -- Repeat procedure by another physician

• Anatomic modifiers (e.g., RT, LT, F1, F2, 50)

• When is it appropriate to bill modifier 50?

• 91 -- Repeat clinical diagnostic laboratory test

• 59 -- Distinct procedural service (Note: Modifier 59 should be utilized only if no other modifier describes the service.)

MUE Effective April 1, 2013, CMS converted some claim line MUEs to date of service (DOS) MUEs.  The total units of service (UOS) from all claim lines for a HCPCS/CPT code with the same date of service will be summed and compared to the MUE value.  Claims denied based on DOS MUEs may be appealed usingsimilar processes to claim line MUE denials.  

CMS does not publish which codes have DOS MUEs.  Since all UOS for a HCPCS/CPT code on all claim lines with the same date of service are summed, reporting additional UOS on separate claim lines with a HCPCS/CPT modifier will not result in payment of UOS in excess of the MUE value.

Key Medicare Benefits for Men’s Health

For those providers servicing Medicare beneficiaries, Men’s Health Awareness Week is a good time for you to re-familiarize yourself with the wide range of covered preventive services.  Identifying risk factors and utilizing screening tests for early detection can mean the difference between life and death. 

As demonstrated by the chart below, several of leading causes of death in males age 65 and over in the United States, are routinely linked to preventable and /or highly treatable causes.  This data was reported by Centers for Disease Control and Prevention for 2009.   

The table below lists the covered service detailing eligibility requirements and other useful billing information:

Service : Procedure Code(s) : Coverage : Frequency

Abdominal Aortic Aneurysm Screening

G0389-U/S exam AAA Screening

Any beneficiaries with certain risk factors and a referral resulting from an IPPE visit.

Once in a lifetime

Alcohol Misuse Screening and Counseling

G0442-Annual screening, 15 min.

G0443-Brief face-to-face behavioral counseling for misuse, 15 min.

For screening: all beneficiaries.

For misuse, furnished by PCP: all competent beneficiaries.

G0442-Once annually

G0443-4 times per year

Annual Wellness Visit (AWV)

G0348-Initial Visit

G0349-Subseqeunt Visit

Any beneficiary that has been effective for Part B for at least 1 year.

G0348- Once in a lifetime

G0349- Once annually

Colorectal and Prostate Cancer Screenings

G0104-Flexible Sigmoidoscopy or G0106-Barium Enema

G0105-Colonoscopy

(high risk) or

G0120-Barium Enema

G0121-Colonoscopy (not high risk)

G0328-Fecal Occult Blood Test immunoassay

82270- Fecal Occult Blood Test by peroxidase activity.

Any beneficiary aged 50 or over who are at normal or high risk for developing

Colo-rectal cancer.

G0328/82270-Once annually

G0104-Once every 4 years or 120 months after G0121

G0121-Once every 10 years or 48 months after G0104 or every 24 months for high risk

G0106/G0120-Once every 48 months or 24 months for high risk.

Cardiovascular Disease Screenings

80061-Lipid Panel

82465-Cholesterol

83718-Lipoprotein

84478-Triglycerides

Any beneficiaries w/o signs or symptoms of cardiovascular disease

Every 5 years

Depression Screening

G0444-Annual screening, 15 min.

Any beneficiary as furnished by PCP with proper support staff.

Once annually

Diabetes Screening

82947-Blood Glucose; quantitative

82950-Glucose;post-glucose dose

82951-Glucose;3 specimen tolerance test

Any beneficiaries with risk factors or diagnoses with pre-diabetes.

Once annually if no pre-diabetes. 

Twice annually with pre-diabetes.

HIV Screening

G0432-Infectious agent by EIS technique

G0433-Infectious agent by ELISA technique

G0435-Infectious agent by rapid antibody test

Any beneficiaries at increased risk for HIV infection or pregnant.

Annually for high risk beneficiaries. 

Three times per pregnancy.

Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)

90654-90657, 90660-90662, Q2034-Q2039-Influenza Virus Vaccine/ G0008 administration 90669-90670,90732-Pneumococcal Vaccine/

G0009-Administration

90740,90743-90744, 90746-90747-Hepatitis B Vaccine/G0010 administration

Influenza and Pneumococcal: all beneficiaries.

Hepatitis B:i any beneficiaries at intermediate or high risk for

Influenza- Once per season.

Pneumococcal- Once in a lifetime.

Hepatitis B- Scheduled dosages as required.

Intensive Behavioral Therapy for Cardiovascular Disease

G0446-IBT to reduce cardiovascular disease risk; individual, face-to-face, bi-annual, 15 min.

Furnished by PCP: Male beneficiaries aged 45-79-encouraging aspirin use, adults aged 18 or older- screening for hypertension, adults with risk factors- promoting a healthy diet

Intensive Behavioral Therapy for Obesity

G0447-Behavioral counseling, face-to-face, 15 min.

Beneficiaries with BMI greater than or equal to 30 kg/m2, furnished by PCP.

One visit per week in first month.

One visit every 2 weeks, months 2-6.

One visit per month, months 7-12.

Prostate Cancer Screening

G0102-Digital rectal exam

G0103-Prostate Specific Antigen test

All male beneficiaries aged 50 and older.

Once annually

Tobacco Use Cessation Counseling

G0436-Counseling for the asymptomatic patient; intermediate >3min. up to 10 min.

G043-Couseling for the asymptomatic patient; intensive, > 10 min.

All outpatient and inpatient beneficiaries.

Two cessation attempts per year: attempt =  max of four sessions, up to eight sessions in 12 months.

For More Information:

• MLN Preventive Services Educational Products for Health Professionals

• CMS Prevention website

• CMS Immunizations website

• MLN National Provider Calls and Events website

• Men’s Health Month website