Frequently Asked Questions

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FAQ

How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value?

For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. The appropriate use of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service) will accomplish this purpose. Modifier 59 may be utilized only if no other appropriate modifier describes the service. For MUEs that are adjudicated as date of service edits, units of service (UOS) in excess of the MUE value may be paid during the appeal process. (See separate FAQ#11344 for information about date of service MUEs.)
(FAQ2277)

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