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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. Tracked using the patient ID, use of different therapists will not override the limits.
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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