Medically Unlikely Edits: Providers Must Bill for Individual Dates, Instead of Span Dating
Highmark applies Medically Unlikely Edits (MUEs) to submitted claims to ensure members receive appropriate, cost-efficient care based on evidence-based, clinical guidelines. Using MUEs, Highmark has detected an increasing number of claims with primary procedure codes being span-dated (or range-dated) while the add-on codes are not, which results in processing errors.

Effective Sept. 22, 2024, Highmark is requiring providers to submit primary codes and add-on codes with individual dates of service vs. a span date. This is to ensure correct processing of the primary and/or add-on code for a specific date.

Span-dated claims that contain primary procedures with add-on codes will be rejected or denied by Highmark.

Background on MUEs

Highmark follows National Correct Coding Initiative (NCCI) guidelines created by the Centers for Medicare and Medicaid Services (CMS). MUEs and NCCI MUE edits are applied to claims based on the values posted by the CMS. Highmark reserves the right to apply MUE edits outside of the CMS values when it is deemed clinically appropriate, or to use statistical methods to determine MUEs when no industry standard MUEs are available.

For more information, see Reimbursement Policy (RP)-035 Correct Coding Guidelines, which is available on the Provider Resource Center. Select CLAIMS, PAYMENT & REIMBURSEMENT from the left menu and click on Reimbursement Policy. Once on the page, type “035” into the search bar.