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Medically Unlikely Edits

Part A providers (TOB 13X, 14X, 85X, 87X): Use the Part A Medically Unlikely Edits tool.

A Medically Unlikely Edit (MUE) value assigned to a CPT/HCPCS code indicates the maximum units of service (UOS) for a single beneficiary on a single date of service (on most appropriately reported claims).

NOTE: Not all CPT/HCPCS codes have an MUE and some MUE values are confidential.

Use this tool to determine the MUE value for a CPT/HCPCS code:

  • Select an effective date (i.e., the appropriate quarter for your date of service).
  • Key the CPT/HCPCS code.
  • Click Search.

If the CPT/HCPCS code has a published MUE, the following information will display:

  • Effective date (based on the quarterly edit update selected)
  • MUE value (maximum UOS for a single beneficiary/date of service)
  • MUE Adjudication Indicator (MAI):
    • 1 Line Edit
      • If you provided medically necessary UOS that exceed the MUE value, you may report separate line-item(s) with the same CPT/HCPCS code and a modifier.
    • 2 Date of Service Edit: Policy
      • These are “per day” edits based on policy (e.g., anatomic considerations, definition of the code, or published CMS policy). CGS won’t pay for services that exceed the MUE value.
    • 3 Date of Service Edit: Clinical
      • These are “per day” edits based on clinical benchmarks. CGS may pay for services that exceed the MUE value if you appeal a claim denial and provide adequate documentation to support medical necessity of correctly reported units.
  • MUE Rationale

Effective Date:

January 1, 2025
October 1, 2024

CPT/HCPCS Code:

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