Health Information Management

Tip: Be prepared for medically unlikely edits

APCs Insider, August 24, 2012

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Medically unlikely edits (MUEs) represent the maximum number of units of a given service that a patient should receive on a given date of service. CMS bases MUEs on several factors, including anatomy, code description, the agency’s own policies, and the overall nature of a service.

CMS has published some, but not all, of the MUEs online. CMS generally does not publish codes with an MUE value of 4 or higher.

Remember that not all CPT and HCPCS codes have MUE values. In fact, the majority of codes will not ­trigger an MUE edit.

It’s also important not to view MUE edits as utilization guidelines. In certain situations, the provider may legitimately decide the patient needs additional units of a specific service.

The tip is adapted from “Differentiate between types of coding edits” in the August Briefings on APCs.

 



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