A Medically Unlikely Edit (MUE) is a Medicare

Centers for Medicare and Medicaid Services

The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...

 unit of service claim edit applied to Medical claims

Medical billing (United States)

Medical billing & coding is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government-owned...

 against a procedure code

Procedure codes

Procedure codes are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals.-International:...

 for medical services rendered by one provider/supplier

Health care provider

A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....

 to one patient

Patient

A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....

 on one day. Claim edits compare different values on medical claim to a set of defined criteria to check for irregularities, often in an automated claims processing system. MUE 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 medical claims. MUE is part of the National Correct Coding Initiative

National Correct Coding Initiative

The National Correct Coding Initiative is a set of rules provided by the United States Centers for Medicare and Medicaid Services to prevent incorrect payment for Medicare Part B claims. It is updated annually....

 (NCCI) to address coding methodologies. The NCCI policies are based on coding conventions by nationally recognized organizations and are updated annually or quarterly.

History

Medically Unlikely Edits began in January 2007 they are generally based on biological considerations, like number of limbs or organs. They adjudicate on units billed per line of service. The same code billed on different lines for the same date of service are subject to duplicate adjudication edits where CPT Modifiers like 59, 76 and 77 may impact the payment . The edits were not publicly released until 2009 with some of them remaining confidential out of concern for abuse
. MUE are not intended to be utilization guide lines, units less than listed may be inappropriate.

It is difficult to establish to what extent private payers are using NCCI edits. Other than published CMS edits there are no nationally recognized code edits: Though there have been proposals to create some. A 2005 study found that private payers were applying “CPT codes, guidelines and conventions”, “CMS payment rules”, “National Correct Coding Initiative”, and “Payer-specific proprietary edits” to claim, of these about 25% were “Payer-specific proprietary edits”