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Medically Unlikely Edits

Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims.

An MUE for a HCPCS/CPT code is the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE.

Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS contractors use only. Confidential MUE values are not releasable. The public/confidential status of MUEs may change over time.

Inquiries about the MUE program, including those related to the National Correct Coding Initiative (NCCI) (PTP, MUE and Add-On) edits, should be sent to NCCIPTPMUE@cms.hhs.gov. Inquiries about a specific claim should be addressed to the appropriate MAC.

To determine the maximum UOS a provider would report under most circumstances for a single beneficiary on a single date of service:

  • Select the appropriate quarterly edit date.
  • Enter the CPT/HCPCS code.
  • Click Search.
  • If CMS has a published MUE for the CPT/HCPCS code, the following will display:
    • Effective date of the quarterly edits selected
    • The MUE value (the maximum unit of service reported under normal circumstances)
    • MUE Adjudication Indicator (MAI) (the type of MUE)
    • MUE Rationale (the underlying basis for each MUE)

MUE Adjudication Indicator (MAI)

The MAI provides the rationale for the edit.

  • MAI 1: Claim Line Edit. 
    • You may add a modifier to bill the same code on separate lines of a claim to identify additional medically necessary units over the MUE value.
  • MAI 2: Absolute Date of Service Edit. 
    • These are "per day" edits based on policy. CGS will not pay in excess of the MUE value.
  • MAI 3: Date of Service Edit. 
    • These are "per day" edits based on clinical benchmarks. CGS may pay over the MUE value at the appeals (Redetermination) level if there is adequate documentation of medical necessity to support additional units.

Select Effective Date:

January 1, 2024
October 1, 2023

Enter HCPCS/CPT Code:

RESOURCES

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