CurrentMolina HealthcarePolicy N/A

National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUE) reimbursement policy

Governs Molina Healthcare's application of CMS NCCI coding edits and Medically Unlikely Edits (MUEs) to claims processing for Medicare, Marketplace, and Medicaid lines of business and notes state exceptions where specified.

Policy Summary

PayerMolina Healthcare

PolicyNational Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUE) reimbursement policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must follow industry standard coding practices; improper billing may result in claim denial and recovery of payments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyNCCI update cadence

by the 15thMolina implementation timing

3 MUE filesMUE file types

A4253: MUE=1Illustrative MUE example

Medicare/Marketplace/MedicaidLines of business applied

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Application of NCCI and MUE Edits

NCCI/MUE application rules

Molina applies CMS NCCI and MUE edits as follows:

Apply CMS Medicare NCCI edits to Medicare and Marketplace claims.

Apply CMS Medicaid NCCI edits to Medicaid claims.

MUEs define maximum units of service per beneficiary per date of service; not all HCPCS/CPT codes have an MUE.

If billed units exceed the MUE for the code on a claim line, the entire claim line will be denied.

MUEs are daily limits and apply even when a separate benefit limit exists (example: A4253 has an MUE of 1 per day even if monthly coverage allows 3 boxes).

Providers billing on a UB04 must bill each date as a separate line item; providers billing on a 1500 may generally bill date spans.

Molina implements NCCI/MUE updates on a quarterly cadence and will apply updates by the 15th of the month following the CMS effective date.

State exceptions

Michigan Medicaid: MUEs are based on limits set in CHAMPS.

Codes, MUE Limits, and Examples

Illustrative HCPCS CodesHCPCS

A4253

Box of 50 glucose test strips (example used to illustrate an MUE of 1 per day)

MUE per code per beneficiary per date of service

ScopeMUEs set maximum units per code per beneficiary per date of service (daily limits) as specified in the CMS MUE files.

ApplicabilityIf billed units exceed the MUE value for a code on a claim line, the entire claim line will be denied.

MUE file typesCMS publishes three MUE files: Practitioners; ASCs and outpatient hospitals; and DME providers.

Interaction with benefit limitsMUEs apply as daily limits even when a separate benefit limit (e.g., monthly quantity) exists.

Billing form notesProviders using UB04 must bill each date as a separate line; providers using 1500 can generally bill date spans.

Billing, Documentation, and Denial Behavior

Denial Risk

MUE Denial Behavior

MUEs (Medically Unlikely Edits) set the maximum units of service that would be unlikely to be correctly billed on a single claim line. If more units than the MUE value are reported on a claim line, the entire claim line will be denied. MUEs are daily limits and apply even when a separate benefit limit exists. Providers billing UB-04 must submit each date of service as a separate line; providers billing on the CMS-1500 or electronic formats may bill date spans when appropriate.

MUEs are established per code and are daily limits.
If billed units > MUE for that code on a claim line, the entire claim line will be denied.
UB-04 billing: submit each date of service as a separate line item.
CMS-1500/electronic billing: date spans may be billed when appropriate.

Key Terms

CMS — definition

Agency nameCenters for Medicare & Medicaid Services (CMS).

RoleFederal agency within the U.S. Department of Health and Human Services that administers the Medicare program and partners with states to administer Medicaid and CHIP.

Related activitiesDevelops and publishes coding programs and edits used for claims processing, including NCCI and MUEs.

MUE — definition

DefinitionMedically Unlikely Edits (MUE) are units-of-service edits that define the maximum units of service that would be unlikely if the claim is reported correctly.

Daily limitsMUEs are applied as daily limits (per beneficiary per date of service).