Reason Code 52MUE - JF Part A

Reason Code Narrative

BEGINNING WITH DATES OF SERVICE ON AND AFTER 01/01/07; IT HAS BEEN DETERMINED THAT ALL LINE ITEMS ON THE CLAIM HAVE UNITS OF SERVICE THAT ARE IN EXCESS OF THE MEDICALLY REASONABLE DAILY ALLOWABLE FREQUENCY. 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). NOTE: THIS REASON CODE IS ASSIGNED EFFECTIVE FOR CLAIMS RECEIVED ON OR AFTER 04/01/2010.

Common Reason Code Errors

• Units at claim level are billed in excess for the allowable units based on the National Correct Coding Initiative (NCCI) edits for Medically Unlikely Edits (MUE)

Common Reason Code Corrections

• If the units of service can be justified, a Redetermination can 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

• CMS National Correct Coding Initiative Edits
  • Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only.

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