Reason Code 53MUE - JE Part A

Reason Code Narrative

IT HAS BEEN DETERMINED THE UNITS OF SERVICE ARE IN EXCESS OF THE MEDICALLY REASONABLE DAILY ALLOWABLE FREQUENCY FOR HCPCS WITH AN MAI OF 2. 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). THIS REASON CODE WILL NOT ASSIGN ON REVENUE LINES WITH A HCPC MODIFIER OF Q3 OR REVENUE CODES 96X, 97X OR 98X.

Common Reason Code Errors

• Units at line 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.

View reason code list, return to Reason Code Guidance page.