What are Medically Unlikely Edits (MUEs)

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Medically Unlikely Edits (MUEs) are a cost saver for insurance companies, but for providers, they can be a bane to fitters and billers alike.

What exactly are Medically Unlikely Edits (MUEs) and why do we need to stay on top of there numbers?

Originally, CMS developed Medically Unlikely Edits (MUEs) on January 1, 200,7 to reduce the paid claims error rate for Part B claims.  MUEs are applicable to Carriers, Fiscal Intermediaries, and DME MAC. An MUE for a HCPCS code is the maximum number of units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.  But Not all HCPCS codes have an MUE. And although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors’ use only.

MUEs are a cost saving factor, but having these relatively unknown, statically derived “maximum number of services” has unintended consequences that affect both the provider and the patient. 

We as Certified Fitters should strive to provide all and only medically necessary services, regardless of MUEs.

Note:  AABCP has assigned a committee with the purpose of researching and requesting a reconsideration of MUEs for post mastectomy products. (8/18)