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.