General Question for the Week of August 28, 2017

General Compliance Question of the Week

Question:

Is there an appeal process for units of service denied based on medically unlikely edits (MUEs)?

Answer:

Units of service (UOS) denied due to a claim-line MUE or a date-of-service MUE may be appealed. According to the Centers for Medicare & Medicaid Services (CMS), appeals should be submitted to local contractors (rather than the MUE contractor). Contractors adjudicating appeals will determine whether the appropriate HCPCS or CPT® code and number of UOS are reported and whether the UOS reported are medically reasonable and necessary. Contractors may pay UOS in excess of the MUE value if the contractor determines that they are medically reasonable and necessary.

CPT® is a registered trademark of the American Medical Association.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.