Policy No: 120
Originally Created: 11/01/2014
Section: Administrative
Last Reviewed: 04/01/2024
Last Revised: 04/01/2024
Approved: 04/11/2024
Effective: 05/01/2024
Policy applies to: Group and Individual & Medicare Advantage
This policy applies to physicians, other qualified health care professionals and facility providers.
ClaimsXten™ Inappropriate Frequency Billing
Developed by Lyric to supplement CMS MUEs.
Medically Unlikely Edits (MUEs)
Edits developed by the Center of Medicare & Medicaid Services (CMS) to reflect the maximum units of services that a provider may report for a patient on a single date of service.
Medically Unlikely Edits Adjudication Indicator (MAI)
CMS' three levels of MUE adjudication indicators using claim line or date of service editing.
- MAI 1: Applied at line level (claim line) – Appropriate use of modifiers to report the same code on separate lines of a claim will enable the reporting of medically necessary units of service in excess of MUE.
- MAI 2: Absolute criteria (date of service) – CMS has not identified any instances in which a higher value is payable.
- MAI 3: Value unlikely to appear on correctly coded claim but could, in unusual circumstances, be payable (date of service) – Exceptions rare, supporting documentation required.
Our health plan uses the CMS MUEs and associated MAIs for maximum daily unit edits. Submission of units within the CMS unit limit will ensure accurate adjudication and reimbursement of claims. Units that have exceeded the maximum daily limitation will be denied.
Our health plan reserves the right to modify the maximum limit and/or reassign MAI to codes on the CMS MUE tables. We also reserve the right to assign a maximum limit to codes not included in the CMS MUE tables. The codes with a unit maximum not shown on the CMS MUE tables may be applied in ClaimsXten Inappropriate Frequency Billing. More information about ClaimsXten editing can be found in the ClaimsXten Editing section of our Coding Toolkit.
CMS Practitioner Services MUE Table
CMS DME Supplier Services MUE Table
CMS Facility Outpatient Services MUE Table
CMS, National Correct Coding Initiative Edits, Medically Unlikely Edits
None
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.