Medically Unlikely Edits (MUE) Denials for Drugs

If you are receiving Medically Unlikely Edits (MUE) denials, determine if you are billing the appropriate number of units. The MUE limits for drugs are likely based on the manufacturer’s package insert for recommended dosage amount. To address drug MUE denials, providers should check the following:

• Verify that charges are being entered correctly by reviewing the medical records and noting the dosage listed in the code description
• Ensure that the unit conversion factors are correct for the drug description 
• Determine if there is a medically necessary reason to exceed the recommended dosage
• Contact your Medicare contractor if you believe an MUE is unreasonable by emailing The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) mailbox at NCCIPTPMUE@cms.hhs.gov
• Ensure that the correct modifiers are being used
  • The JW HCPCS modifier is required for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded. Providers are required to document the discarded drug or biological in the patient's medical record. The JW HCPCS modifier is only applied to the amount of the drug or biological that is discarded

There will still be MUE denials for drugs even if the above steps are followed. If a drug is denied for a MUE edit, please file an appeal with documentation to support the reason why the drug was administered. Documentation should also include physician orders, the dosage and amount of the drug given, the amount of drug waste and any other pertinent information to support the charges, why the number of units were billed and the medical need for the services. 

Billing Examples

Billing with the JW HCPCS Modifier

The JW HCPCS modifier is only applied to the amount of drug or biological that is discarded. The discarded drug and the amount should be billed on a separate line with the JW HCPCS modifier. Please remember to verify the milligrams given to the patient and then convert to the proper units for billing based on the code descriptor. 

For example: A single use vial is labeled to contain 100 mg/4 mL. The code long descriptor indicates that one (1) billing unit represents 10 mg.

90 mg are administered to the patient and 10 mg are discarded.

The 90 mg administered is billed as nine (9) units on one line, while the discarded 10 mg are billed as one (1) unit on another line with the JW HCPCS modifier.

Both lines will be processed, if the units do not exceed the allowed MUE. If the units exceed the allowed MUE, the lines will be denied. An appeal should be filed with the appropriate documents to support the units billed.

The patients record must clearly indicate the number of units administered and amount discarded.

Billing Without JW HCPCS Modifier

The JW HCPCS modifier is not permitted when the actual dose of the drug or biological administered is less than the HCPCS billing unit. 

Case Example 1

One billing unit of the drug is equal to 10 mg of the drug in a single use vial.

A 7 mg dose was administered to the patient while 3 mg of the drug was discarded.

The 7 mg dose is billed using one billing unit representing 10 mg on a single line item.

The single line item of one (1) unit would be processed for payment of 10 mg of drug administered and discarded.

Billing another unit on a separate line item with the JW HCPCS modifier for the discarded 3 mg of drug is not permitted because it would result in overpayment.

The patient's medical record must clearly indicate the number of units administered and amount discarded.
 

Case Example 2

One billing unit for Zoledronic Acid is equal to 1mg of the drug in a single use vial.

A 3.0 mg dose of the drug was administered to the patient using four units representing 4 mg, while 1.0 mg of the drug was discarded.

The single line item of four (4) units would be processed for payment of 4 mg of drug administered and discarded.

Billing another unit on a separate line item with the JW HCPCS modifier for the discarded 0.50 mg of drug is not permitted because it would result in overpayment.

The patient's medical record must clearly indicate the number of units administered and amount discarded.

References

• CMS Internet-Only Manual, Publication 100-04, Claims Processing Manual, Chapter 17, Section 40 (PDF, 493 KB)
• Medicare Learning Network Matters Article, MM9603 (PDF, 58 KB) — JW Modifier: Drug Amount Discarded/Not Administered to Any Patient
• Medicare Program JW Modifier (PDF, 71 KB): Drug/Biological Amount Discarded/Not Administered to Any Patient Frequently Asked Questions
• National Correct Coding Initiative (NCCI) Frequently Asked Questions