Significance of MUE and MAI in claim processing
Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims.
Understanding why Medically Unlikely Edits (MUEs) were established, how they are organized, and the criteria on which edit rationales are based may help medical coders and billers avoid denials or, at a minimum, properly resolve a denial.
An MUE for a HCPCS/CPT code is the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE.
To determine the maximum UOS a provider would report under most circumstances for a single beneficiary on a single date of service:
-Select the appropriate quarterly edit date.
-Enter the CPT/HCPCS code.
-Click Search.
-If CMS has a published MUE for the CPT/HCPCS code, the following will display:
Effective date of the quarterly edits selected
The MUE value (the maximum unit of service reported under normal circumstances)
MUE Adjudication Indicator (MAI) (the type of MUE)
MUE Rationale (the underlying basis for each MUE)
MUE Adjudication Indicator (MAI)
The MAI provides the rationale for the edit.
MAI 1: Claim Line Edit.
You may add a modifier to bill the same code on separate lines of a claim to identify additional medically necessary units over the MUE value.
MAI 2: Absolute Date of Service Edit.
These are "per day" edits based on policy. CGS will not pay in excess of the MUE value.
MAI 3: Date of Service Edit.
These are "per day" edits based on clinical benchmarks. CGS may pay over the MUE value at the appeals (Redetermination) level if there is adequate documentation of medical necessity to support additional units.
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