Those who are involved in charge capture and claim submission processes are probably familiar with the National Correct Coding Initiative (NCCI) and the procedure-to-procedure edits and medically unlikely edits that apply to the CPT® coding hierarchy for drug administration.

Many, however, (including many hospital pharmacists) are unaware of the medically unlikely edits (MUEs) that the Centers for Medicare & Medicaid Services (CMS) have begun applying to claims for drugs. The MUEs are not procedure-to-procedure (PTP) coding edits and they are not frequency limitations to limit how often a drug may be administered. Instead, MUEs limit the units of service that are billable for a single date of service.

In 2007, CMS implemented unit-of-service (UOS) edits for CPT and HCPCS level II codes. The intent of the MUEs is to limit the number of times that a code is billed on a date of service (DOS), with the end goal of preventing overbilling and reducing the paid claim error rate for outpatient claims. While the MUEs are not new to Medicare’s claim edit process, the addition of MUE values for drugs and for skin substitutes did not begin until July 2014, coinciding with the release of NCCI updates.

Currently there are 350-plus HCPCS entries in the J-code series for drugs that have a published MUE value. With each quarterly release of NCCI table updates, the MUEs continue to expand. Quarterly updates are published on the CMS website here.

In developing MUEs related to pharmacy, CMS established a process that includes review of industry standards and maximum dosage parameters. Final steps in determining an appropriate MUE limit included sharing of information with select organizations – including the American Medical Association (AMA), national medical societies such as the American Society for Clinical Oncology (ASCO), and other national healthcare organizations (such groups also were asked for comments, including feedback related to expected drug utilization and exceptions to standard dosing). CMS may or may not agree with the suggestion of industry stakeholders, however. The final decision for an MUE value assigned to a HCPCS is determined by CMS. The rationale for CMS’s proposal for an edit as well as the industry comments returned to CMS are maintained under a strict level of confidentiality and are not publicly available for review. The CMS website for frequently asked questions provides an email address for submission of inquiries regarding specific HCPCS MUE values: [email protected].

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