Medically Unlikely Edits Now Available


At last, providers and suppliers can review most of the edits that Medicare has put into place to ensure that Medicare is not being billed for excessive services

under Part B through incorrect coding or clerical errors. Beginning October 1, 2008, CMS is publishing a list of Medically Unlikely Edit (MUE) values for about 9,700 HCPCS/CPT codes, to check number of times a service is reported for the same patient on the same date of service for each code so as to improve the accuracy of claims submission. These edits are based on anatomical considerations (e.g., procedures performed on eleven fingers), code descriptors, CPT instructions, CMS policies, the nature of the procedure or service, and the nature of the equipment or analyte involved, and clinical

judgment. The edits will be published on the CMS website at

CMS is withholding from publication those MUE values that it uses to detect and deter questionable payments rather than billing errors. CMS also cautions that the published MUE values should not be construed to be permissible

utilization guidelines, and that only services that are medically necessary and reasonable should be billed.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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