Laboratory Question for the Week of January 10, 2022

Question:

Can you clarify how MUEs are used?

Answer:

To lower the Medicare Fee-For-Service Paid Claims Error Rate, the CMS has established units of service edits referred to as Medically Unlikely Edit(s)(MUEs). An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances allowable by the same provider for the same beneficiary on the same date of service. The ideal MUE value for a HCPCS/CPT code is the unit of service that allows the vast majority of appropriately coded claims to pass the MUE. If the MUE is adjudicated as a DOS MUE, all UOS on each claim line for the same date of service for the same HCPCS/CPT code are summed, and the sum is compared to the MUE value. If the summed UOS exceed the MUE value, all UOS for the HCPCS/CPT code for that date of service are denied. Denials due to claim line MUEs or DOS MUEs may be appealed to the local claims processing contractor. DOS MUEs are used for HCPCS/CPT codes where it would be extremely unlikely that more UOS than the MUE value would ever be performed on the same date of service for the same patient.

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