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Policy No: 120

Originally Created: 11/01/2014

Section: Administrative

Last Reviewed: 01/01/2019

Last Revised: 01/01/2019

Approved:  01/17/2019

Effective:  05/01/2019

This policy applies to  physicians, other qualified health care professionals and facility providers.

Definitions

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.

Policy Statement

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.

References

CMS Practitioner Services MUE Table

CMS DME Supplier Services MUE Table

CMS Facility Outpatient Services MUE Table

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.