Policy No: 120
Originally Created: 11/01/2014
Last Reviewed: 04/01/2020
Last Revised: 04/01/2020
This policy applies to physicians, other qualified health care professionals and facility providers.
Medically Unlikely Edits (MUEs)
Edits developed by the Center of Medicare & Medicaid Services (CMS) to reflect the maximum units of services that a provider may report for a patient on a single date of service.
Medically Unlikely Edits (MAI)
CMS three levels of MUE adjudication using claim line or date of service editing.
ClaimsXten™ Inappropriate Frequency Billing
Developed by Change Healthcare to supplement CMS MUEs.
Our health plan uses the CMS MUEs and associated MAIs for maximum daily unit edits. Submission of units within the CMS unit limit will ensure accurate adjudication and reimbursement of claims.
Our health plan reserves the right to modify the maximum limit and/or reassign MAI to codes on the CMS MUE tables. We also reserve the right to assign a maximum limit to codes not included in the CMS MUE table. The codes with a unit maximum not shown on the CMS MUE tables are applied in ClaimsXten Inappropriate Frequency Billing. More information about ClaimsXten editing can be found in the ClaimsXten Editing section of our Coding Toolkit.
CMS Practitioner Services MUE Table
CMS DME Supplier Services MUE Table
CMS Facility Outpatient Services MUE Table
CMS, National Correct Coding Initiative Edits, Medically Unlikely Edits
CMS, Revised Modification to the Medically Unlikely Edit (MUE) Program, Medicare Learning Network Article #MM853, August 2014
Explanation of CMS MAI values