Insights & Resources

Medically Unlikely Edits (MUEs) are used to flag potential fraud and billing errors for claims by identifying the maximum number of units that a provider reports for a specific code in a single day for an individual patient. While third-party payers are not required to follow CMS’s MUEs, many incorporate them in their claims manuals.

Contrary to the stated objective above, MUEs have periodically limited what would otherwise have been a medically necessary treatment provided by practitioners on the ground that a service exceeded the designated “Unit of Service” (UOS). However, a claim cannot be denied solely on the basis that a service exceeded the designated UOS. CMS’s Policy Manual provides that billing codes with MUE Adjudication Indicator of three (3) may be paid in excess of the MUE based on clinical necessity.

Below is the most recent MUE Table published by CMS delineating each billing code for applied behavior services. As the table below delineates, because all billing codes for applied behavior services has MUE Adjudication Indicator of “3,” providers may be paid in excess of the MUE if services were actually provided, properly coded, and medically necessary. As such, providers who encounter claim denials for the reason above may appeal as long as they properly code and provide proof that the services were necessary.