Reason Code 53MUE

Description
It has been determined the units of service are in excess of the medically reasonable daily allowable frequency for HCPCS with a MAI of 2. 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). This reason code will not assign on revenue lines with a HCPCS modifier of Q3 or revenue codes 96x, 97x or 98x.

Resolution
Units at line level are billed in excess for the allowable units based on the National Correct Coding Initiative (NCCI) edits for Medically Unlikely Edits (MUE). If the units of service can be justified, a Redetermination may be submitted. Redetermination should include:

  • All applicable supporting medical documentation
  • Corrected UB-04 form

If the excessive units were submitted in error, a Redetermination can be submitted. Note: Redeterminations will only review medically denied lines.

Resources

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