AMA CPT® Assistant - 2007 Issue 11 (November)
Update: Medically Unlikely Edits (November 2007)
November 2007 pages 6-7 Update: Medically Unlikely Edits The December 2006 CPT Assistant included a Q&A with notification of a new set of edits from the Centers for Medicare and Medicaid (CMS) called the Medically Unlikely Edits (MUE). Now that these edits are in place, the following is intended to provide you with additional information on this particular set of CMS edits. Background The MUEs are units of service (UOS) edits for a HCPCS/ CPT code which reflect the maximum number of UOS that a provider might report for the same HCPCS/CPT code for the same beneficiary on...
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Article Overview
This article provides a high-level overview of CMS Medically Unlikely Edits (MUEs) and their role in Medicare claims processing. It is aimed at coders, billers, and compliance-focused readers who need to understand the scope of these edits, how CMS describes their purpose, and the broad categories of factors that can affect units of service. The discussion also notes the phased rollout of MUEs, the organizations involved, and where CMS-related reference material can be found.
Why This Topic Matters
MUEs can affect whether claim lines are paid, denied, or returned, so understanding the edit framework is important for accurate reporting and compliance. This article helps readers recognize the policy context and the major types of considerations CMS uses when setting these edits.
Article Sections
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November 2007 pages 6-7
Publication context for the CPT Assistant update and the CMS editing topic covered in the article.
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Background
Introduces CMS Medically Unlikely Edits, explains their general purpose, and describes how they relate to claim-line processing and Medicare claims review.
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Phases of Edits
Summarizes the staged implementation of MUEs and the broad categories of considerations described for different phases of the edit program.
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More Information
Points readers to CMS and related professional organizations for additional reference material and general background on the edit set.
What You Will Learn
- The general purpose of CMS Medically Unlikely Edits
- How MUEs fit into claim-line adjudication at a high level
- The broad categories of factors CMS describes as influencing MUE values
- The phased implementation approach referenced in the update
- Where to find additional CMS-related information on the topic
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Physician practice staff
- Hospital revenue cycle staff
Modifiers Discussed
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