Medically Unlikely Edit

Last updated

A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day. Claim edits compare different values on medical claim to a set of defined criteria to check for irregularities, often in an automated claims processing system. MUE are designed to limit fraud and/or coding errors. They represent an upper limit that unquestionably requires further documentation to support. The ideal MUE is the maximum unit of service for a code on the majority of medical claims. [1] MUE is part of the National Correct Coding Initiative (NCCI) to address coding methodologies. The NCCI policies are based on coding conventions by nationally recognized organizations and are updated annually or quarterly. [2]

History

Medically Unlikely Edits began in January 2007 [3] they are generally based on biological considerations, like number of limbs or organs. They adjudicate on units billed per line of service. [4] The same code billed on different lines for the same date of service are subject to duplicate adjudication edits where CPT Modifiers like 59, 76 and 77 may impact the payment. [4] [5] The edits were not publicly released until 2009, with some of them remaining confidential out of concern for abuse [6] . [7] MUE are not intended to be utilization guidelines. Units less than listed may be inappropriate. [8]

It is difficult to establish to what extent private payers are using NCCI edits. [9] Other than published CMS edits, there are no nationally recognized code edits, although there have been proposals to create some. [10] A 2005 study found that private payers were applying "CPT codes, guidelines and conventions", "CMS payment rules", "National Correct Coding Initiative", and "Payer-specific proprietary edits" to claim, of these about 25% were "Payer-specific proprietary edits" [11]

Related Research Articles

Medicare (United States) United States single-payer national social insurance program

Medicare is a national health insurance program in the United States, begun in 1966 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It primarily provides health insurance for Americans aged 65 and older, but also for some younger people with disability status as determined by the SSA, and people with end stage renal disease and amyotrophic lateral sclerosis.

Resource-based relative value scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all health maintenance organizations (HMOs).

Medical billing is a payment practice exclusively within the United States health system. The process involves a healthcare provider submitting, following up on, and appealing claims with health insurance companies in order to receive payment for services rendered; such as testing, treatments, and procedures. The same process is used for most insurance companies, whether they are private companies or government sponsored programs: Medical coding reports what the diagnosis and treatment were, and prices are applied accordingly. Medical billers are encouraged, but not required by law, to become certified by taking an exam such as the CMRS Exam, RHIA Exam, CPB Exam and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field. Some community colleges in the United States offer certificates, or even associate degrees, in the field. Those seeking advancement may be cross-trained in medical coding or transcription or auditing, and may earn a bachelor's or graduate degree in medical information science and technology.

Dual-eligible beneficiaries refers to those qualifying for both Medicare and Medicaid benefits. In the United States, approximately 9.2 million people are eligible for "dual" status. Dual-eligibles make up 14% of Medicaid enrollment, yet they are responsible for approximately 36% of Medicaid expenditures. Similarly, duals total 20% of Medicare enrollment, and spend 31% of Medicare dollars. Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries.

The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

Healthcare reform in the United States has a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010, which amended the PPACA and became law on March 30, 2010.

Split billing is the division of a bill for service into two or more parts. Bills may be split to divide work between clients, payers or for reimbursement to different service providers for performing a shared service.

The National Correct Coding Initiative (NCCI) is a Centers for Medicare & Medicaid Services (CMS) program designed to prevent improper payment of procedures that should not be submitted together. There are two categories of edits:

Current Dental Terminology (CDT) is a code set with descriptive terms developed and updated by the American Dental Association (ADA) for reporting dental services and procedures to dental benefits plans. Prior to 2010 many of the codes were published by Centers for Medicare and Medicaid Services (CMS) as HCPCS D-codes under arrangement with the ADA. Ownership and copyright of CDT remained with the ADA. In 2010 the ADA ended the CMS distribution of CDT codes, which can now be purchased from the ADA.

Evaluation and management coding is a medical coding process in support of medical billing. Practicing health care providers in the United States must use E/M coding to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters.

An accountable care organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".

Connolly, Inc

Connolly, LLC is a private, global-recovery audit firm with more than 1,200 employees, and two divisions Global Retail and Healthcare. The company is headquartered in Wilton, Connecticut. Recovery auditing is a financial best practice recognized by leading organizations worldwide for reducing clients' erroneous payments, improving their processes, and enhancing their performance. Connolly’s clients include many of the world’s largest and best run companies in virtually all industries.

The Healthcare Common Procedure Coding System is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).

The Center for Medicare and Medicaid Innovation is an organization of the United States government under the Centers for Medicare and Medicaid Services (CMS). It was created by the Patient Protection and Affordable Care Act, the 2010 U.S. health care reform legislation. CMS provides healthcare coverage to more than 100 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace.

HCPCS Level II codes are alphanumeric medical procedure codes, primarily for non-physician services such as ambulance services and prosthetic devices,. They represent items, supplies and non-physician services not covered by CPT-4 codes. Level II codes are composed of a single letter in the range A to V, followed by 4 digits. Level II codes are maintained by the US Centers for Medicare and Medicaid Services (CMS). There is some overlap between HCPCS codes and National Drug Code (NDC) codes, with a subset of NDC codes also in HCPCS, and vice versa. The CMS maintains a crosswalk from NDC to HCPCS in the form of an Excel file. The crosswalk is updated quarterly.

The Specialty Society Relative Value Scale Update Committee or Relative Value Update Committee is a volunteer group of 31 physicians who have made highly influential recommendations on how to value a physician's work when computing health care prices in the United States' public health insurance program Medicare.

American College of Pathology

The American College of Pathology (ACP), founded in 2012, is a non-profit professional medical association composed of diagnostic pathologists, physicians, and laboratory professionals. It is based in Houston, TX, with offices in Houston, TX, and Washington, D.C. The college publishes The Journal of the American College of Pathology (JACP) and The ACP Bulletin.

All-payer rate setting is a price setting mechanism in which all third parties pay the same price for services at a given hospital. It can be used to increase the market power of payers versus providers, such as hospital systems, in order to control costs. All-payer characteristics are found in most developed economies with multi-payer healthcare systems, including France, Germany, Japan, and the Netherlands. The U.S. state of Maryland also uses such a model.

Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets sanctioned by the Health Insurance Portability and Accountability Act in the United States.

The Oncology Care Model (OCM) is an episode-based payment system developed by the Center for Medicare and Medicaid Innovation. The multipayer model is designed for discrete instances of care, especially those involving chemotherapy, which triggers the six-month episode. The program combines fee-for-service (FFS) payments for established services, monthly payments for additional care under a structured guideline, and performance-based payments weighed against quality metrics and benchmarks.

References

  1. ↑ CMS (September 25, 2009). "What is a Medically Unlikely Edit (MUE)?" (web). Q&A. Centers for Medicare and Medicaid Services . Retrieved January 21, 2010.
  2. ↑ CMS (October 1, 2009). "National Correct Coding Initiatives Edits; Overview" (web). CMS Rule. Centers for Medicare and Medicaid Services . Retrieved January 21, 2010.
  3. ↑ CMS (January 1, 2010). "Medically Unlikely Edits" (Web). CMS Rule. Centers for Medicare and Medicaid Services . Retrieved January 21, 2010.
  4. 1 2 ACRO (2009). "Putting it into Perspective – Medically Unlikely Edits" (PDF). Article. American College of Radiation Oncology . Retrieved January 21, 2010.
  5. ↑ CMS (September 25, 2009). "How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value?" (web). Q&A. Centers for Medicare and Medicaid Services . Retrieved January 21, 2010.
  6. ↑ Lansey, Debra (February 2009). "Follow the changes to Medicare coding edits for early 2009" (web). Article. American College of Physicians . Retrieved January 21, 2010.
  7. ↑ HCPro (October 7, 2008). "Busy week: OIG Work Plan, CMS' MUE list available" (web). Article. HCPro . Retrieved January 21, 2010.
  8. ↑ CMS (September 25, 2009). "Has CMS published the Medically Unlikely Edit (MUE) values for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes?" (web). Q&A. Centers for Medicare and Medicaid Services . Retrieved January 21, 2010.
  9. ↑ ACSO (2008). "Do private payers use the NCCI edits established by CMS?" (web). Journal of Oncology Practice, Vol 4, No 3 (May), 2008: pp. 116-117. American Society of Clinical Oncology . Retrieved January 21, 2010.
  10. ↑ AMA (June 2005). "FEASIBILITY STUDY ON THE DEVELOPMENT OF CPT COMPLIANT CODE EDITS" (PDF). Report. American Medical Association . Retrieved January 21, 2010.
  11. ↑ NHXS (2005). "What private payers do to your claim: repricing and claims editing" (PDF). review of report by National Health Exchange Services (NHXS). American Medical Association . Retrieved January 21, 2010.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.