The Centers for Medicare and Medicaid Services (CMS) developed the Medically Unlikely Edit (MUE) program to reduce the paid claims error rate for Part B claims. The first edits were implemented on January 1, 2007. Subsequently, there have been quarterly updates increasing the number of edits. The edits were developed based on anatomic considerations, HCPCS/CPT code descriptors, CPT instructions, CMS policies, nature of service/procedure, nature of the analyte, nature of the equipment, and clinical judgment. Prior to implementation, all edits were reviewed by national healthcare organizations, and their alternative recommendations were taken into consideration.
MUEs differ from the National Correct Coding Initiative (NCCI) edits. The NCCI edits identify which procedures and services are bundled and should not be billed together. MUEs limit the number of times a service or procedure can be reported by a physician on the same date of service to an individual patient. MUEs apply not only to services and procedures but also to durable medical equipment and drugs. CMS developed the MUE program to reduce the error rate for Part B coding and to control improper payments. The edits are based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instruction, CMS policies, nature of service or procedure, and nature of analyte or equipment. Generally speaking, the MUEs are considered a tool for limiting fraud and abuse activity, which has become a focus of the agency over the past few years.
A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day. Claim edits compare different values on the medical claim to a set of defined criteria to check for irregularities, often in an automated claims processing system. MUEs are designed to limit fraud and/or coding errors. They represent an upper limit that unquestionably requires further documentation to support. The ideal MUE is the maximum unit of service for a code on the majority of the medical claims. MUE is part of the National Correct Coding Initiative (NCCI) to address coding methodologies. The MUE Durable Medical Equipment Supplier Services for the third quarter of 2017 are released on the CMS website on June 02, 2017 and will be effective from July 1, 2017 to September 30, 2017.