Medically Unlikely Edits
The DME MACs use the National Correct Coding Initiative's Medically Unlikely Edits to reduce improper claim payments. An MUE is (a) the maximum units of service reported for a code on the vast majority of appropriately-reported claims (b) by the same provider/supplier for (c) the same beneficiary on (d) the same date of service. Many commercial payers also follow the NCCI's MUE guidance. In this post, we will summarize the MUE's for both bracing and prosthetic codes.
What You Need to Know:
Bracing L Codes MUE's
MUE of 0:
L0984, L2840, L2850, L2861, L3215, L3219, L3260, L3265, L3891
MUE of 1:
L0112, L0113, L0120, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0220, L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0700, L0710, L0810, L0820, L0830, L0859, L0861, L0970, L0972, L0974, L0976, L0980, L0982, L1000, L1001, L1005, L1025, L1030, L1040, L1050, L1060, L1085, L1090, L1200, L1220, L1230, L1240, L1260, L1300, L1310, L1499, L1600, L1610, L1620, L1630, L1640, L1650, L1652, L1660, L1680, L1685, L1686, L1690, L1700, L1710, L1730, L2006, L2040, L2050, L2060, L2070, L2080, L2090, L2300, L2310, L2627, L2628, L2630, L2640, L2660, L3140, L3150, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3254, L3255, L3257, L3640, L3650, L3671, L3674, L3677, L3678, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L4000.
MUE of 2:
L0978, L1010, L1020, L1070, L1080, L1100, L1110, L1210, L1250, L1280, L1290, L1720, L1755, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1851, L1852, L1860, L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2570, L2580, L2600, L2610, L2620, L2622, L2624, L2650, L2670, L2680, L2795, L2800, L2820, L2830, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3160, L3170, L3216, L3217, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3330, L3332, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3980, L3981, L3982, L3984, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4100, L4130, L4350, L4360, L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631
MUE of 3:
L1120, L1270, L3933, L3935.
MUE of 4:
L2200, L2210, L2220, L2385, L2387, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2760, L2768, L2785, L2810, L3300, L3310, L3320, L3334, L3925, L3927, L3956, L3995, L4090, L4110, L4210.
MUE of 8:
L2750, L2755, L2780, L4002, L4205
Prosthetic L Codes MUE's
MUE of 0:
L5969, L7600
MUE of 1:
L5961, L7360, L7362, L7364, L7366, L7368
MUE of 2:
L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5676, L5677, L5678, L5680, L5681, L5682, L5683, L5684, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L6000, L6010, L6020, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6386, L6388, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6670, L6672, L6675, L6676, L6677, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L7367, L7400, L7401, L7402, L7403, L7404, L7405, L7700
MUE of 4:
L5618, L5620, L5622, L5624, L5626, L5673, L5679, L5685, L6632, L6655, L6660, L6665, L6680, L6682, L6684, L7510
MUE of 5:
L6715
MUE of 12:
L7520
What This Means for You:
Medicare created MUE values to reduce the paid claims error rate for Medicare claims. More specifically, MUE's are designed to reduce errors from both clerical entries and incorrect coding based on a range of different criteria.
A claim that includes units of service in excess of the MUE value will result in Medicare denying the L-code at issue in its entirety for that claim. So, for example, if you submit a claim that includes more than two units of service for L1843 or L5981 - both of which have a MUE of 2 - those codes will get denied.
Importantly, Medicare has made an allowance for the fact that in certain clinical situations, providing units of service in excess of the MUE cap may be medically necessary. You can appeal the denial of certain L-codes billed with units of service in excess of the MUE cap and receive payment for them if there is adequate documentation of medical necessity. Those L codes are:
Bracing:
L0220, L0978, L0982, L0984, L1020, L1025, L1030, L1040, L1050, L1060, L1090, L1120, L1210, L1220, L1240, L1250, L1260, L1270, L1280, L1290, L1499, L1686, L2006, L2270, L2275, L2320, L2330, L2380, L2397, L2627, L2628, L2650, L2660, L2670, L2680, L2750, L2755, L2760, L2768, L2780, L2785, L2820, L2830, L2840, L2850, L2861, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3219, L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3334, L3671, L3674, L3891, L3912, L3916, L3925, L3927, L3933, L3935, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3995, L4002, L4070, L4090, L4110, L4205, L4210, L4392, L4394
Prosthetics:
L5000, L5410, L5430, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5654, L5655, L5656, L5658, L5661, L5665, L5668, L5673, L5679, L5684, L5685, L5688, L5690, L5695, L5699, L5859, L5925, L5961, L5969, L6386, L6611, L6632, L6641, L6642, L6655, L6660, L6665, L6680, L6682, L6684, L6691, L6692, L6694, L6695, L6715, L6810, L6890, L6895, L7360, L7364, L7367, L7510, L7520, L7600
Knowing the MUE unit of service limits ahead of time can help you avoid denials for exceeding those caps. In addition, understanding that you can get payment for units of service in excess of the MUE cap by adequately documenting medical necessity allows you to draft clinical notes that address this issue directly.
For more information from Medicare about MUE's, click here.