The CMS developed MUEs to reduce the paid claims error rate. 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.
MUE values are not utilization guidelines. They do not represent units of service reported without concern about medical review. Continue to report services that are medically reasonable and necessary.
Please visit the CMS Medically Unlikely Edits page to search for MUEs that affect your claims. If you want to submit a request for reconsideration of an MUE value, please include your rationale and any supporting documentation.
If you have questions or comments about the NCCI program you may submit inquiries related to NCCI (PTP, MUE and AOCs) edits in writing via email to ncciptpmue@cms.hhs.gov
Questions cannot be answered outside the scope of NCCI or about other CMS programs. For example, questions about modifiers not associated with NCCI, LCDs, changes to code descriptors or status indicators should be directed to the local MACs.
Review these important points:
If you report a code with units greater than the MUE value assigned, the line and/or claim will deny
Be aware of the description of a HCPCS/CPT code when billing a service:
Initial
Subsequent
Single level
Second level
Many HCPCS/CPT codes have common or similar terms, but there are differences in the description. Some examples include:
Bilateral
Unilateral
Greater than
Less than
With
Without
MUEs do not exist for all HCPCS/CPT codes
When requested, records should explain why the patient required more than the approved MUE for any service
Documentation submitted must support the units of service billed as reasonable and necessary
When billing, append the appropriate modifiers
While the majority of MUEs are publicly available on the CMS website, CMS will not publish all MUE values because of fraud and abuse concerns
CMS updates MUEs quarterly
The MUE adjudication indicator (MAI) indicates the type of MUE and its basis. The MAI assigned to HCPCS/CPT codes will determine how your claim will process and/or deny.
The MAI types are listed in the charts below.
MAI of “1” |
MUEs for HCPCS codes with a MAI of “1” will continue to be adjudicated as a claim line edit May require modifiers to distinguish: Repeat services Anatomic differences |
MAI of “2” |
MUEs for HCPCS codes with a MAI of “2” are absolute date of service edit These are “per day edits based on policy” Based on statue, description of HCPCS/CPT code, or coding guidance CMS gives no instances in which a higher value would be correct and payable Expectation is provider will not bill above allowable MUE |
MAI of “3” |
MUEs for HCPCS codes with a MAI of “3” are date of service edits These are “per day edits based on clinical benchmarks” Appealed additional units are considered if there is adequate documentation of medical necessity to support reported units |
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