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Medically Unlikely Edits

Notice:  The MUE file for the third quarter of 2014 has been updated to contain two additional fields of information.  One field indicates whether each MUE is a claim line or date of service edit.  (See MLN SE1422.)  The second field provides the rationale for each MUE.  Information about MUE rationales is available in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1, Section V (Medically Unlikely Edits).  Although the usual formatted version of the MUE file published July 1, 2014 and the updated version published July 3, 2014 are available on the CMS website in the third quarter of 2014, only the updated MUE file format will be available in future calendar quarters.

The CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims.  An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.  All HCPCS/CPT codes do not have an MUE.

MUE was implemented January 1, 2007 and is utilized to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs.

This webpage has links to the MUE Frequently Asked Questions and Answers (FAQs), MUE files, and the Publication Announcement Letter which explain most aspects of the MUE program.

Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only.  The latter group of MUE values should not be released since CMS does not publish them.

Inquiries about the MUE program other than those related to MUE values for specific HCPCS/CPT codes should be sent to the following email address: NCCIPTPMUE@cms.hhs.gov.

Inquiries about a specific claim should be addressed to the claims processing contractor.

Inquiries about the rationale for an MUE value should be addressed to your claims processing contractor or a national healthcare organization whose members often perform the procedure.

If a national healthcare organization, provider, or other party wants to submit a request for reconsideration of an MUE value, the procedure described in the MUE Frequently Asked Questions (FAQ) should be followed.  See the web link below.  Such requests should be addressed to:

National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907

Fax #:  317-571-1745