LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

2013-01 Medically Unlikely (MUEs) and Clinically Unbelievable Edits (CUEs)

January 25, 2013

Medically Unlikely (MUEs) and Clinically Unbelievable Edits (CUEs)

CGS is receiving an increase in the number of inquires about Medically Unlikely Edits (MUEs) and Clinically Unbelievable Edits (CUEs).

The Centers for Medicare and Medicaid Services (CMS) created MUEs to reduce the paid claim error rate for Part B claims. An MUE for a HCPCS code is the maximum units of service that a provider would bill under most circumstances for a single beneficiary on a single date of service. These edits are set to deny claim lines exceeding the acceptable maximums. The denials are identified by ANSI Reason Code 151 with Remark Code N362 on the remittance advice.

Most MUE values are published by CMS but some are confidential and are for CMS and CMS Contractors’ use only. Additional information on MUEs and the published values may be viewed on CMS’s website at-CLICK-HERE.

Similar to MUEs, Clinically Unbelievable Edits (CUEs) were created by Medicare Contractors as an initiative to reduce the paid claim error rate. Providing supplies in excess of the utilization parameters outlined in a particular Local Coverage Determination (LCD) and/or Policy Article is often the result of multiple suppliers servicing the same beneficiary. Claims for supplies that exceed clinically unbelievable parameters are automatically denied as not reasonable and necessary. CUE denials are identified by ANSI Reason Code 151 with Remark Code N115 or N362. Unlike MUE values, all CUE values are kept confidential.

Suppliers may request a redetermination with medical documentation to support the need for excessive items for denials issued based on MUE and CUE values. When clerical/billing errors occur and denials are issued based on MUE edits, suppliers may request a claim reopening to correct the number of units or span of dates however all denials based on CUE edits require a redetermination.

Additionally, Advance Beneficiary Notices of Noncoverage (ABNs) may not be issued for units of service in excess of MUEs. ABNs cannot be issued once items are denied based on MUEs to transfer financial responsibility and bill the beneficiary.