Appeal reminder for medically unlikely edits (MUEs)

An MUE for a CPT or HCPCS code is the maximum units of service a provider would report under most circumstances for a single beneficiary on a single date of service. As referenced in the National Correct Coding Initiative (NCCI) Policy Manual, contractors will review medical records to determine if the units of service were rendered, coded correctly, and were reasonable and necessary. Requests to allow up to or over the MUE value will require documentation to support these elements.

First Coast Service Options would like to remind providers medical documentation needs to be submitted when filing a redetermination or clerical error reopening for a claim (or line item) denied due to an MUE. 

Documentation reminders 

• Documentation must support the medical necessity of all services rendered to the beneficiary.
• Documentation must support the units billed were truly provided, correctly coded and reasonable and necessary.
  • Please review claim submission to ensure you are billing correctly prior to requesting a redetermination or clerical error reopening.
• Complete documentation should be specific to the type of service you are appealing.
• Consider the following as you prepare the medical documentation to send:
  • All copies of the medical documentation include the patient's name and are complete and legible.
  • Physician's signature, date, and time are on the appropriate medical documentation.
  • Services in question requiring a physician's order must include a copy of a signed, dated, and timed order.
  • Appropriate diagnosis is documented to support the service billed.
  • Service was billed correctly with the appropriate procedure code and number of units.
  • Medical documentation must:
    • Support the services are reasonable and necessary.
    • Provide detail to support the furnished units of service reported on the claim.
    • Provide the rationale and medical reasonableness for performing over the maximum units of service.

References

• Medically unlikely edits
• National Correct Coding Initiative
• Appeals Center
• Submit claim corrections & reopenings electronically