Medically Unlikely Edits Lookup Tool

Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for claims.

An MUE for a HCPCS/CPT code is the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE.

Although CMS 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.

Inquiries about the MUE program, should be sent to NCCIPTPMUE@cms.hhs.gov. Inquiries about a specific claim should be sent to us.

If a national healthcare organization, provider, or other party wants to submit a request for reconsideration of an MUE value, the procedure described in the CMS Frequently Asked Questions (FAQs) should be followed. Such requests should be sent to NCCIPTPMUE@cms.hhs.gov.

To determine the maximum units of service (UOS) a provider would report under most circumstances for a single beneficiary on a single date of service:

• Select the appropriate quarterly edit date
• Enter the CPT/HCPCS code
• Select Search
• If CMS has a published MUE for the CPT/HCPCS code, the following will display:
  • Effective date of the quarterly edits selected
  • The MUE value (the maximum unit of service reported under normal circumstances)
  • MUE Adjudication Indicator (MAI) (the type of MUE)
  • MUE Rationale (the underlying basis for each MUE)

MUE Adjudication Indicator (MAI)

The MAI provides the rationale for the edit.

• MAI 1: Claim Line Edit 
  • You may add a modifier to bill the same code on separate lines of a claim to identify additional medically necessary units over the MUE value
• MAI 2: Absolute Date of Service Edit 
  • These are "per day" edits based on policy. Palmetto GBA will not pay more than the MUE value.
• MAI 3: Date of Service Edit 
  • These are "per day" edits based on clinical benchmarks. Palmetto GBA may pay over the MUE value at the appeals (Redetermination) level if there is adequate documentation of medical necessity to support additional units.

Reminder: Documentation must be maintained in the patient's medical record to support that the number of services billed were performed and that all the services were medically necessary. This is true for units up to and over the MUE value. If after reviewing documentation it is felt the individual patient’s documentation supports an allowable exception to the MUE, the provider may exercise their individual claim appeal rights and provide the necessary supporting documentation with their appeal request.

Resources

• CMS Medically Unlikely Edits Webpage
• CMS Medicare Learning Network booklet, "How to Use the Medicare National Correct Coding Initiative Tools"