Move Over Q1 MUEs … April 1 Changes Are Coming

April 2018 MUE updates


Hey, early birds. Have you checked out the Q2 updates to Medically Unlikely Edits (MUEs)? CMS provides spreadsheets showing quarterly updates so you can see the changes and start preparing ahead of time. Here are some highlights from the changes effective April 1, 2018, to existing practitioner MUE values, along with some tips on understanding what MUEs are.

Start With a Quick MUE Refresher

When you look up the MUE for a code, what you’re seeing is the maximum units of service Medicare expects a provider to report for a single beneficiary on a single date of service. Medicare doesn’t create MUEs for all codes, and it doesn’t publish all the MUEs it creates. But for a lot of codes, you can look up the MUE to check the units you’re reporting against the MUE value. (If you have a TCI SuperCoder online coding solution that includes Medicare fee schedule data, the fee schedule is where you’ll find MUEs posted.)

When you check the MUE, also look at the MUE Adjudication Indicator (MAI):

  • MAI 1 is a claim line edit, meaning that when documentation supports reporting additional units of the same code, you may report those units on an additional claim line as long as each individual line doesn’t go over the MUE value.
  • MAI 2 indicates a policy-based date of service (DOS) edit. For MUEs with MAI 2, the payer will sum the units you report for the code for a single beneficiary on a single DOS. The payer will deny claim lines that go over the MUE value. Medicare hasn’t found a scenario yet where exceeding the MUE for these codes is OK.
  • MAI 3 is another DOS edit, but these are clinically based. As with MAI 2, payers sum all the units you report for that code for a beneficiary on one DOS. But unlike MAI 2, payers may allow excess units for MAI 3 MUEs based on appeal or documentation proving medical necessity.

Don’t miss: We’re focused on practitioner MUEs in this post, but there are facility outpatient and DME supplier MUEs, too, and each category may have a different value for the same code.

Check Both MUE Values and MAIs for Spine Codes

In this post, we’re looking at a few of the existing MUEs that change values on April 1. First are the spine surgery codes +22853, +22854, and +22859, which will switch their MUE values from 5 to 4. All three are add-on codes that represent biomechanical device insertion. You report +22853 per interspace and codes +22854 and +22859 for each contiguous defect.

Tip: The MAIs for these MUEs is changing, too. Before April 1, the MAI for each is 1 (line edit). Starting April 1, the MAI will be 3 (clinical DOS edit).

Go From 2 to 1 for Endovascular Repair Code MUEs

New endovascular repair add-on codes +34713, +34714, +34715, and +34716 started off the year with MUE values of 2 and MAI 2 (policy DOS edit).

As of April 1, the MAIs will still be 2, but the MUE values will change to 1 for each of these codes. Here’s a quick look at what these codes represent. Note the term “unilateral” in each descriptor:

  • +34713 (Percutaneous access and closure of femoral artery for delivery of endograftunilateral …)
  • +34714 (Open femoral artery exposure with creation of conduit unilateral …)
  • +34715 (Open axillary/subclavian artery exposure for delivery of endovascular prosthesis unilateral …)
  • +34716 (Open axillary/subclavian artery exposure with creation of conduitunilateral …)

Fit the Pieces Together for Athletic Eval Change

Athletic training evaluation codes 97169-97172 will change to MUE 0 from 1. That’s not as big a change as it may seem because already in the first quarter of 2018, the codes have a code status of I (Not valid for Medicare purposes) and 0 RVUs on the Medicare Physician Fee Schedule.

Report 1 for Initial Moderate Sedation Codes

Moderate sedation services 99151, 99155, and 99156 will change MUE values from 2 to 1 on April 1.

Each of these codes applies to the initial 15 minutes of intraservice time. The MAIs remain 3 (clinical DOS edit), so if there’s some rare case where a patient requires two separate initial moderate sedation services on the same date, the payer may allow units in excess of the MUE if there was medical necessity.

What About You?

How do you keep up with quarterly updates to MUEs? Do you have to check manually, or do you have online coding software that includes updates?



Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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