Medically unlikely edits or MUE are designed to help reduce the number of billing errors, but have the potential to create obstacles within the pharmacy revenue cycle. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services was developed to encourage consistent and correct coding thereby reducing inappropriate payments.
The NCCI Policy Manual for Medicare Services contains 13 narrative chapters in which chapter XII which addresses HCPCS Level II codes and MUE. Each quarter the NCCI is updated to reflect changes from 3 sources 1) additions, deletions, or modifications in the CPT manual or HCPCS 2) CMS policy initiatives and 3) comments from the American Medical Association and other national or locally recognized healthcare organizations. It is important to note that all NCCI edits will auto-deny a claim but may be appealed.
A MUE value represents the maximum number of units of service or billed units for a given HCPCS or CPT that are allowable for the same provider, same beneficiary on the same date of service. Each HCPCS or CPT is associated with a MUE Adjudication Indicator or MAI along with the MUE value. An MAI of “1” indicates that the edit is a claim line edit and a modifier may be necessary when billed in excess of an MUE. An MAI of “2” is a per date of service based on policy and has undergone a rigorous review. It would be impossible to justify a claim that has been billed in excess of the MUE limit as it would be contrary to statute, law or other subregulatory guidance. An MAI of “3” are per day edits based on clinical benchmarks. It would be possible but medically unlikely that a service would exceed an MUE value. If the provider can provide evidence to the Medicare contractor for the services billed in excess these auto-denials may be overturned.
The majority of drugs and biologics are represented with a MAI of “3”. CMS uses several factors when determining the MUE value for drugs and biologicals. Some of these factors include maximum daily dose based on prescribing data, maximum daily dose calculated based on body weight and other published material related to the drug or biological. These attributes are evaluated in combination with claims data to develop the final value for the MUE.
The MUE values for a HCPCS or CPT are located on the CMS website under the NCCI subsection (here). The file contains the HCPCS and CPT, representing MUE value, MAI and the MUE rationale. For example, J9041 (bortezomid (Velcade) 0.1 mg) has a MUE value of 35 and an MAI of 3. This means when any dose above 3.5 mg is billed on the same date of service to a beneficiary, the claim will auto-deny. Bortezomid dose is based on body surface area in which some patients may exceed a dose of 3.5 mg. In this case, the claim must be appealed.
Collaborate! Understanding and appropriately appealing MUE denials lends itself to collaboration among pharmacy, billing and denial teams.
- Monitor denials that are due to excess MUE.
- Validate the claims were billed appropriately based on the service provided.
- Appeal the denial if there is evidence to support its use.