What are Medically Unlikely Edits?

Many provides have a good understanding of the National Correct Coding Initiative (NCCI) edits utilized by the Centers for Medicare and Medicaid Services (CMS) as well as other commercial insurance carriers, including some workers compensation carriers. However, most providers of outpatient therapy services are either unaware or lack a solid understanding of CMS’ medically unlikely edits (MUEs). In this article, I will answer the following questions:

1. What are medically unlikely edits (MUEs)?
2. What outpatient therapy practice settings does CMS apply MUEs to?
3. Are there different MUEs for a private practice (submit claims on a 1500-claim form) and a facility-based provider (submits claims on a UB-04 claim form)?
4. How are MUEs adjudicated by my Medicare Administrative Contractor?
5. What does an MUE Adjudication Indicator (MAI) mean?
6. Do MUEs apply to Medicare Advantage plans as well as traditional Medicare?
7. What are the MUEs for some of the more common CPT codes billed by physical and occupational therapists?
8. For physical therapy (PT) and occupational therapy (OT) billing under the same group/facility NPI and Tax ID number, do the MUEs for each CPT code apply individually to each discipline or combined PT and OT when the MAI is a “3”?
9. What are the MUEs for some of the more common CPT codes billed by speech-language pathologists?
10. How often are MUEs updated?

Let’s begin!

Question #1
What are medically unlikely edits (MUEs)?

Answer #1

Question #2
What outpatient therapy practice settings does CMS apply MUEs to?

Answer #2

Question #3
Are there different MUEs for a private practice (submit claims on a 1500-claim form) and a facility-based provider (submits claims on a UB-04 claim form)?

Answer #3

Question #4
How are MUEs adjudicated by my Medicare Administrative Contractor?

Answer #4

Question #5
What does an MUE Adjudication Indicator mean?

Answer #5

Question #6
Do MUEs apply to Medicare Advantage plans as well as traditional Medicare?

Answer #6

Question #7
What are the MUEs for some of the more common CPT codes billed by physical and occupational therapists?

Answer #7

Question #8
For physical therapy (PT) and occupational therapy (OT) billing under the same group/facility NPI and Tax ID number, do the MUEs for each CPT code apply individually to each discipline or combined PT and OT when the MAI is a “3”?

Answer #8

Question #10
How often are MUEs updated?

Answer #10

I hope you found this article helpful and informative. Thank you for being a Gold Member!

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