Reason Code 54MUE - JF Part A

Reason Code Narrative

IT HAS BEEN DETERMINED THE UNITS OF SERVICE ARE IN EXCESS OF THE MEDICALLY REASONABLE DAILY ALLOWANCE FREQUENCY FOR HCPCS WITH AN MAI OF 3. THE EXCESS CHARGES DUE TO UNITS OF SERVICE GREATER THAN THE MAXIMUM ALLOWABLE MAY NOT BE BILLED TO THE BENEFICIARY.

THIS REASON CODE WILL NOT ASSIGN ON REVENUE LINES WITH A HCPC MODIFIER OF Q3 OR REVENUE CODES 96X, 97X, OR 98X.

THIS REASON CODE IS BYPASSED WHEN A 55 MODIFIER IS PRESENT. THIS REASON CODE WILL NOT ASSIGN ON A TOB 12X, 13X, 14X, AND 76X WHEN A SERVICE LINE IS PACKAGED (IOCE SERVICE INDICATOR FLAG EQUALS N AND PAYMENT INDICATOR FLAG 2 EQUALS 9 ON CLAIM PAGE 31) FOR CLAIMS RECEIVED ON OR AFTER 07/01/19.

Common Reason Code Errors

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

Common Reason Code Corrections

• If units of service can be justified, a Redetermination can be submitted. Redetermination should include:
  • All applicable supporting medical documentation
  • Corrected UB-04 form
  • If excessive units were submitted in error, a Redetermination can be submitted.
• Note: Redeterminations will only review medically denied lines.
• Is there a LCA, LCD, NCD, or Medicare policy linked to code under review?
  • If yes, does submitted documentation support medical necessity?
  • If no, was correct HCPCS/CPT code billed, was correct UOS billed/reported correctly?

Resources

• National Correct Coding Initiative Edits
• Medically Unlikely Edits | CMS
  • Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS Contractor’s use only.

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