Medically Unlikely Edits Go Public, Thanks to CMS

October 22, 2008

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The Centers for Medicare and Medicaid Services (CMS) developed the Medically Unlikely Edit (MUE) program to reduce the paid claims error rate for Part B claims. The first edits were implemented January 1, 2007, and there have been subsequent quarterly updates increasing the number of edits. The edits were developed based on anatomic considerations, HCPCS/CPT code descriptors, CPT instructions, CMS policies, nature of service/procedure, nature of analyte, nature of equipment, and clinical judgment.

Prior to implementation, all edits were reviewed by national healthcare organizations, and their alternative recommendations were taken into consideration. Starting in 2008, CMS has been refining the edits based on one hundred percent of submitted claims data from a six-month period in 2006.

In September, CMS announced that, starting October 1st, a majority of these code edits would be made public and posted on the CMS website. These edits will be updated on a quarterly basis and will contain some code edits of a value of 4 or more.

The MUEs are not meant to replace utilization guidelines—MUE values do not represent units of service that may be reported without concern about medical review. Providers should report only services that are medically reasonable and necessary.

Review CMS Information on MUEs.

Contact Gina Gjorvad at ggjorvad@aan.com, (651) 695-2715, with any additional questions.