November 2007
The College of American Pathologists (CAP; Northfield, IL) and the American Clinical Laboratory Association (ACLA; Washington, DC) have renewed their call for Medicare to disclose the "medically unlikely edits" (MUEs) that limit the units of service that can be billed daily for a particular CPT/HCPCS code per beneficiary.
Originally referred to as medically unbelievable edits, MUEs were designed to improve the accuracy of Medicare expenditures by preventing inappropriate payments. MUEs are used by local contractors to weed out claims that exceed MUE limits and automatically reject them.
CAP and ACLA were responding to a request from the Centers for Medicare & Medicaid Services (CMS) for comment on its policy restricting MUE distribution, which the agency has said is necessary to prevent providers from "gaming" the system. ACLA and CAP said that public disclosure is essential if providers are to submit accurate claims and avoid unwarranted denials. Otherwise, providers will not know when to apply an appropriate modifier to bypass the edit, and efforts to educate providers on MUEs and modifier use would be stymied.
ACLA’s position is that full knowledge of the MUEs will allow claims to be submitted according to the CMS-established rules. The organization considers MUEs to be in the same category as National Correct Coding Initiative edits, which are fully disclosed to the public. ACLA also noted that because there is no MUE-specific remark code, those who process claims and denials will not know an MUE triggered the rejection until they have ruled out all other possibilities.
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