November 10, 2017

CMS Accepts Appeal for Higher MUE Values

The American College of Radiology (ACR) and American College of Obstetricians and Gynecologists (ACOG) have prevailed in their joint appeal to the Centers for Medicare & Medicaid Services (CMS) for higher Medically Unlikely Edit (MUE) values for two fetal interventional procedures involving ultrasound guidance.

On Oct. 30, CMS announced it will revise its previous edit for the MUE values of CPT codes 59074 Fetal fluid drainage (e.g., vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance and 59076 Fetal shunt placement, including ultrasound guidance. As requested, the MUE value for these procedures will be increased from 1 to 2. The change will be implemented on Jan. 1, 2018, and will appear in the Medicaid National Correct Coding Initiative (NCCI) MUE files.

The MUE value is the maximum units of service that a provider may report under most circumstances for a single beneficiary on a single date of service. Payment claims for procedures involving more units than the MUE value are routinely denied initially. However, providers can gain payment by submitting an appeal with adequate documentation of medical necessity to substantiate the unusual circumstances.

The appeal, filed by the ACR and ACOG on Sept. 27, asked CMS for an Medicaid MUE value 2 for CPT codes 59074 and 59076 to equal the Medicare MUE value of 2 for these procedures because the codes may be reported twice in the case of twin fetuses. In addition, a rare possibility exists for the performance of two, separate, medically necessary procedures, such as thoracentesis and paracentesis, on the same singleton fetus.

In response to the successful appeal, CMS Medicaid will make payments for any denied claims, based on the MUE value of 2 for both codes. Payments will be retroactive to July 1, 2017, the date when this edit was developed. After July 1, 2017, any claims that were denied based on this edit may be resubmitted for payment.

Please contact your local Medicaid carrier for more details regarding claims resubmission.