Medically Unlikely Edits for Jan. 2007

In order to lower the Medicare paid claims error rate, CMS established units of service edits referred to as MUEs. The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs.

  • An MUE is defined as an edit that tests claim lines for the same beneficiary, HCPCS code, date of service, and billing provider against a criteria number of units of service.
  • The MUEs will auto-deny claim line items containing units of service billed in excess of the MUE criteria or Return to Provider (RTP) claims that contain lines that have units of service that exceed an MUE criteria.
  • MUEs that will be implemented by this notice are based on anatomic considerations. CMS will allow an appeals process for those claim line items that are denied as a result of an MUE edit.
  • An appeals process will not be allowed or required for claims that are RTPÕed. Providers should resubmit corrected claims.
  • This set of MUEs based on anatomical considerations addresses approximately 2,800 codes. Affected clinical lab services are Pap smear screening - G0123, G0124, G0143, G0144, G0145 - whose MUEs are set at one.
  • Excess charges due to units of service greater than the MUE may not be billed to the beneficiary or subject to an ABN.

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