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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medically Unlikely Edits Guide

Medically Unlikely Edits (MUE) represent the maximum number of units that can be billed at the claim line or for a date of service per patient.  

HCPCS codes with an Adjudication of “1” are adjudicated as a claim line edit.  

HCPCS codes with an Adjudication of “2” are absolute date of service edit. These are “per day edits based on policy”. HCPCS codes with a “2” have been rigorously reviewed and vetted within CMS and obtain this designation because units of service (UOS) on the same date of service (DOS) in excess of the MUE value would be considered impossible because it was contrary to the regulations.

HCPCS codes with an Adjudication of “3” are date of service edits. These are “per day edits based on clinical benchmarks”. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units.

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