CMS has established unit of service edits, titled Medically Unlikely Edits (MUE), to lower Medicare’s fee for service paid claims error rate. MUEs, which are housed by the National Correct Coding Initiative (NCCI) contractor, are defined as edits that check specific claim lines for the same beneficiary, HCPCS code, date of service, and billing provider against a predefined number of units of service.
If a unit of service is reported in excess of the MUE criteria for that HCPCS code, Medicare contractors, specifically Carriers and MACs, will deny the entire claim line when the units of service are in excess of MUE criteria for claims processed via the VIPS MEDCARE Shared System and Medicare Claims System.
Fiscal intermediaries and A/B MACs will Return to Provider claims with units of service that exceed MUE criteria and pay other services on the claims as part of the initial claims processing activities for claims processed via the FISS system. Each MUE has an effective date that determines which claims the MUEs will affect.
MUEs are updated quarterly and the information regarding these updates can be found in CMS Transmittals. Refer to the CMS Web site at http://www.cms.hhs.gov/Medical ReviewProcess/ for futher information on MUEs.