Understanding Medicare's Medically Unlikely Edits

What exactly are Medically Unlikely Edits (MUE)?
MUEs place maximums on the number of units of service per CPT code that can be reported by a provider for the same patient on the same date of service.  Items billed above the established number of units are automatically denied as a “Medically Unlikely Edit.”

Do all CPT codes have an assigned MUE?
No, not all CPT codes are assigned an MUE.  Most of the CPT codes with an assigned MUE are published by Medicare who updates the table quarterly.  MUEs are assigned for a variety of reasons, such as policy or statutory restrictions, clinical benchmarks, etc.  Not all MUEs are published, however; some are kept confidential by CMS. The published 2015 MUE table for Practitioners can be found at:

http://www.cms.gov/apps/ama/license.asp?file=/NationalCorrectCodInitEd/downloads/2015-MCR-MUE-PractitionerServices.zip

Following are 2 tables of example MUE’s.  The first table lists pathology services that can be reported and billed above the listed MUE value as long as there is documentation in the report to that effect. The second table lists a few examples of pathology services that can’t be reported above the MUE value.

Note: The above MUE’s are appealable and payable provided services are documented and substantiate the number of units.

Note: The above pathology services are not appealable and are absolute limits.

APS Medical Billing performs ongoing editing and programming enhancements in order to meet the parameters of CMS’ billing initiatives including this MUE program, the National Correct Coding Initiative (NCCI edits), National and Local Coverage Determinations (NCD/LCD), and the Physician Quality Reporting System (PQRS).   Additional information on CMS’ Medically Unlikely Edits program can be found at:  http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/08_MUE.asp