MUE

Medically Unlikely Edits

The MUE file for the third quarter of 2014 has been updated to contain two additional fields of information.  One field indicates whether each MUE is a claim line or date of service edit.  (See MLN SE1422.)  The second field provides the rationale for each MUE.

Information about MUE rationales is available in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1, Section V (Medically Unlikely Edits).  Although the usual formatted version of the MUE file published July 1, 2014 and the updated version published July 3, 2014 are available on the CMS website in the third quarter of 2014, only the updated MUE file format will be available in future calendar quarters.

The CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims.  An MUE for a 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.  All HCPCS/CPT codes do not have an MUE.

MUE was implemented January 1, 2007 and is utilized to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs.

This webpage has links to the MUE Frequently Asked Questions and Answers (FAQs), MUE files, and the Publication Announcement Letter which explain most aspects of the MUE program.

Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only.  The latter group of MUE values should not be released since CMS does not publish them.

WEB: NCCIPTPMUE@cms.hhs.gov.