Medically Unlikely Edits (MUE)

2011 Update: Medicaid MUEs are now included, so there are 6 different MUE tables.  To get to this info, you have 2 choices, browse or search.

Browse:

• On the left-hand navigation pane of your product, click on the Coding Guidance link
• Scroll down Code Edits and Crosswalk Section and open the folder “CMS - Medically Unlikely Edits (MUE)”
• In there are six tables: Medicare/Medicaid and Hospital, Practitioner, DME for each.
• We notice that MOST MUEs match, but there can be differences.
• If you want to download the files directly, got to first page “Medically Unlikely Edits”

Search:

• If you are using Advanced Code Explorer, for any code you can click on the GUIDANCE link. If there are any MUEs for that code, you’ll see the CMS – Medically Unlikely Edits in your search results; expand to see the MUEs spelled out on screen.

According to CMS FAQ #8734:

An MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum unit of service that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. The MUE program provides a method to report medically reasonable and necessary UOS in excess of an MUE.

CMS began implementation of MUEs for HCPCS/CPT codes on January 1, 2007. Until this month, CMS did not publish these edits, but they have recently been added to the CMS site, and republished on MediRegs.

You can access the outpatient and dme MUE lists on the MediRegs product in the coding guidance library. If you perform a product-wide advanced search for MUE*, you will also find helpful CMS FAQs, transmittals and manuals, NCCI Guidelines and other pertinent information to help you understand this important edit.