Update: Medically Unlikely Edits Rule and Orthotics Devices and Procedures

August 7, 2014

As a reminder, in May 2013 Blue Cross and Blue Shield of Oklahoma (BCBSOK) implemented the Medically Unlikely Edits (MUE) Rule established by the Centers for Medicare & Medicaid Services (CMS). CMS determines the defined limits on utilization that apply to a number of Current Procedural Terminology (CPT®) codes. When the number of units submitted on a claim exceeds the MUEs established by CMS, a denial may be triggered for those particular services. It is the responsibility of providers to monitor any MUE changes that may be published by CMS.

Effective Jan. 1, 2014, CMS added "Off the Shelf" to the descriptor of many HCPCS codes for Orthotic Devices and Procedures. Some claims may have denied in error after CMS changed the value for many codes in the MUE rule to "0." BCBSOK has resolved this system issue. If providers have claims affected by this issue, they may contact their Provider Network Representative.

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