CMS MUE : Automated claim processing

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 Some MUE values are confidential and may not be published.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

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 once annually

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.