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Developed by the Centers for Medicare and Medicaid Services (CMS) the Medically Unlikely Edits (MUEs) are used “to reduce the improper payment rate for Part B claims.” The Medically Unlikely Edits (MUEs) are specifically designed to be used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs. It is important to note that “an MUE for an HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service”. However, some of the HCPCS/CPT codes do not have an MUE assigned to them.

According to CMS, it “publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS contractors use only. Confidential MUE values are not releasable. The public/confidential status of MUEs may change over time.” Therefore, any inquiry related to specific MUE should be addressed to the appropriate MAC and should not be sent to NCCIPTPMUE@cms.hhs.gov.

Understanding Medically Unlikely Edits

Medically Unlikely Edits are based on anatomical considerations wherein units of service (UOS) may be limited based on structures, CPT code descriptors that may limit units of service, CMS policies that also may limit units of service, clinical judgment considerations, and determination that are based on input from physicians and certified coders may limit units of service, and submitted claims data wherein a six-month time-frame is used to ascertain the distribution pattern of UOS typically billed for a given CPT code.

There are three MUE three tables such as Durable Medical Equipment (DME), Facility, and Practitioner. It’s important to refer to the relevant MUE table to avoid any error while accessing the MUE values, MUE adjudication indicators (MAIs), and MUE rationales for every HCPCS Level II/CPT code as the edits vary among each set. The practitioner table is used by physicians and other qualified health care practitioners.

The three MUE tables can be accessed by visiting CMS website at
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.

Adjudication of Medically Unlikely Edits

The National Correct Coding Initiative (NCCI) clarifies that MUEs are adjudicated either as claim line edits or DOS edits. Source: https://www.cms.gov/medicare/national-correct-coding-initiative-edits/
ncci-faqs

• If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the Health care Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code on that claim line.
• If the UOS on the claim line exceeds the MUE value, all UOS for that claim line is denied.  If the same code is reported on more than one line of a claim by using CPT modifiers, each line of the claim is adjudicated separately against the MUE value of the code on that claim line.
• If the MUE is a DOS MUE, all UOS for the HCPCS/CPT code reported by the same provider/supplier for the same beneficiary for the same DOS are summed.  The summed value is compared to the MUE value.  If the sum is greater than the MUE value, all UOS for the code on the current claim is denied.