Those who are involved in charge capture and claim submission processes are probably familiar with the National Correct Coding Initiative (NCCI) and the procedure-to-procedure edits and medically unlikely edits that apply to the CPT® coding hierarchy for drug administration.
Many, however, (including many hospital pharmacists) are unaware of the medically unlikely edits (MUEs) that the Centers for Medicare & Medicaid Services (CMS) have begun applying to claims for drugs. The MUEs are not procedure-to-procedure (PTP) coding edits and they are not frequency limitations to limit how often a drug may be administered. Instead, MUEs limit the units of service that are billable for a single date of service.
In 2007, CMS implemented unit-of-service (UOS) edits for CPT and HCPCS level II codes. The intent of the MUEs is to limit the number of times that a code is billed on a date of service (DOS), with the end goal of preventing overbilling and reducing the paid claim error rate for outpatient claims. While the MUEs are not new to Medicare’s claim edit process, the addition of MUE values for drugs and for skin substitutes did not begin until July 2014, coinciding with the release of NCCI updates.
Currently there are 350-plus HCPCS entries in the J-code series for drugs that have a published MUE value. With each quarterly release of NCCI table updates, the MUEs continue to expand. Quarterly updates are published on the CMS website here.
Rationale for MUE Value
In developing MUEs related to pharmacy, CMS established a process that includes review of industry standards and maximum dosage parameters. Final steps in determining an appropriate MUE limit included sharing of information with select organizations – including the American Medical Association (AMA), national medical societies such as the American Society for Clinical Oncology (ASCO), and other national healthcare organizations (such groups also were asked for comments, including feedback related to expected drug utilization and exceptions to standard dosing). CMS may or may not agree with the suggestion of industry stakeholders, however. The final decision for an MUE value assigned to a HCPCS is determined by CMS. The rationale for CMS’s proposal for an edit as well as the industry comments returned to CMS are maintained under a strict level of confidentiality and are not publicly available for review. The CMS website for frequently asked questions provides an email address for submission of inquiries regarding specific HCPCS MUE values: NCCIPTPMUE@cms.hhs.gov.
An existing MUE value may be revised on a quarterly basis, when CMS publishes updates for the NCCI tables. A revised MUE is not retroactive unless the change is issued with a retroactive date. To request a reconsideration of a MUE value, providers may submit a request accompanied by supporting documentation and rationale for the request to the following address or fax number:
National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
When Billed Units Exceed MUE Value
MUE claim resolution is necessary when the billed UOS exceeds the MUE limitation for a single date of service. Determining if the limitation is based on a line-item value or a date-of-service value is accomplished through review of the MUE adjudication indicator or MAI assigned to each code.
- When a MUE limit is associated with the MAI of 1, the claim line is adjudicated separately against the MUE value for the HCPCS code on that line.
- A MAI of either 2 or 3 represents a DOS edit, for which each line for the same HCPCS will have the UOS added together for that DOS. The total value will be adjudicated against the total of all line items.
Types of MUEs and Adjudication
Prior to April 1, 2013, each claim line was adjudicated separately against the MUE value for the CPT or HCPCS code reported. If the UOS on that claim line exceeded the MUE value, the entire claim line was denied. In the April 1, 2013 version of MUE, CMS converted some claim-line MUEs to date-of-service (DOS) MUEs. All MUE edits for drugs and skin substitutes are adjudicated as DOS limits based on clinical data or established prescribing information.
If the MUE is adjudicated as a claim-line edit, the UOSs are compared to the MUE value for the code submitted. If the UOS exceeds the MUE value, all UOS entries on that claim line are denied. If the MUE is adjudicated as a DOS MUE, all UOSs on each claim line for the same DOS for the same code are summed, and the sum is compared to the MUE value. If the summed UOSs exceed the MUE value, all UOSs for the code for that DOS are denied.
When a MUE policy is defined as a DOS MUE, the allowable unit of service may not be bypassed by appending a modifier. A review of the medical record must be completed to determine if a billing error occurred.
Claim Edit Reconciliation
The drug dose for administration, as requested by the physician or other prescribing provider, is only one factor that determines the UOS reported on the claim. A drug dispensed from a single-dose vial may be reported on the claim with a HCPCS-billed UOS that exceeds the dose administered and is equal to the total volume of the vial. Data entry at the time a drug is first received into inventory and entered into the pharmacy information system will impact the math applied for conversion of a dispensed unit of measure (UOM) to the HCPCS-defined unit of service (UOS). Close attention to the relationship between the HCPCS code description and the drug label information as defined for the NDC is an integral component of ensuring that all information is accurately entered into the pharmacy module. Any error in entry of information to the drug formulary can result in incorrect reporting of the HCPCS billed UOS.
The pharmacy, acting on physician order, prepares and dispenses the drug based upon this request. Assuming that all patient-safety guidelines and documentation requirements are met, the drug charge, the HCPCS code, revenue code, and billable unit populate the claim with no further consideration by the pharmacy until the claim is denied. At this point the pharmacy will become engaged in discussion of the potential reason for denial only if the department is notified of the denial.
Once an outpatient claim is denied, the billing office needs to determine how to reconcile the edit in order to resubmit the claim for payment, which prompts questions like the following:
- Is the pharmacy routinely notified regarding claim denials that include payer denial of drug reimbursement?
- Does the reconciliation mean removing the UOSs that impact reimbursement?
- Does reconciliation of a claim edit occur without the pharmacy knowing there was an issue?
- Is there inquiry to determine why a drug MUE value has been exceeded?
- Did the UOS reported on the claim accurately represent the drug administered?
- Was there a calculation error that resulted in over-reporting the UOS?
- Did the amount of drug wasted from a single-dose vial result in the UOS exceeding the MUE value?
- Did the MUE edit identify incorrect billing of waste volume from a multi-dose vial?
If after review of documentation it is determined that the UOS was reported in error, a corrected claim would be submitted. Appeal of a claim denial is allowed when it is determined that the UOS submitted correctly represents the drug administered (and wasted, if indicated) and documentation in the medical record supports that administration was medically indicated and medical necessity guidelines have been met.
A MUE denial is a coding denial and not a medical necessity denial. Use of the advance beneficiary notice of non-coverage (ABN) to shift financial liability to the beneficiary would not be appropriate.
About the Author
Robin Zweifel is a senior vice president of revenue capture services for Panacea Healthcare Solutions Inc. Robin’s areas of expertise include clinical laboratory and chargemaster management, as well as infusion and pharmacy regulatory compliance.
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