CMS Reveals Edits Used to ID Part B Claims Errors

BALTIMORE–On Oct. 1, CMS began publishing on its Web site the
system edits it uses to detect certain billing errors.

Begun in January last year to reduce overpayments for Part B
claims, the Medically Unlikely Edit program tests claims for the
same beneficiary, billing code, date of service and provider
against a number of units of service. An MUE for a HCPCS/CPT code
is the maximum units of service that a provider would report under
most circumstances for a single beneficiary on a single date of
service.

Originally called Medically Unbelievable Edits, the program was
designed to block improbable claims, such as services billed for a
test that exceeds Medicare frequency limits (Medicare pays for only
one diagnostic mammogram per year, for example) or procedures that
could not have been performed on a particular patient (such as a
hysterectomy on a man).

The MUE program has grown from edits for about 2,600 HCPCS/CPT
codes to edits for about 9,700, although CMS has not yet determined
if there have been any savings since the program was implemented,
according to an agency release. And because the MUE program also
sorts questionable payments that could be linked to fraud and
abuse, some of the edits will remain confidential, according to
Kimberly Brandt, director of CMS’ Program Integrity
Group.

For the edits and more information about the MUE program, click here.