Please Note: There is no Medicare information on our corporate website. Please select a specific contract in the 'Search Within' box for Medicare related information.
© 2021 Palmetto GBA, LLC
We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version.
Published Date:12/16/2019
Printed Date: 9/22/2015
URL: http://palmgba.com/marlowe/redesign6/article.html
Description Beginning with dates of service on and after 01/01/07, it has been determined the units of service are in excess of the medically reasonable daily allowable frequency for HCPCS with a MAI of 1. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary and; this provision can neither be waived nor subject to an advanced beneficiary notification (ABN). Note: this reason code is assigned effective for claims received on or after 04/01/2010. This reason code is bypassed when a 55 CPT modifier is present.
Resolution Units at line level are billed in excess for allowable units based on National Correct Coding Initiative (NCCI) edits for Medically Unlikely Edits (MUE). If units of service can be justified, a Redetermination may be submitted. Redetermination should include:
If the excessive units were submitted in error, a Redetermination may be submitted.
Note: Redeterminations will only review medically denied lines.
Resource
CMS National Correct Coding Initiative Edits — Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only.
CMS Medicare Learning Network (MLN) Matters Special Edition (SE)1422 (PDF, 392 KB)
We value your opinion and want to provide the highest-quality and most relevant Medicare knowledge possible. Please let us know if this article was helpful.
It didn't answer my question This article was helpful
We’re glad we could help you today and appreciate your feedback. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information.
We're sorry this article didn't help you today. We'll use your feedback to review this article to try to revise or expand it. Contact us with more feedback or a question on this topic.
Last Updated: 12/16/2019