New Payment Policy: Medically Unlikely Edits

A new informational payment policy has been created called “Medically Unlikely Edits (MUEs)/Maximum Units of Service.”

This policy explains the establishment of maximum daily units on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes. These maximum daily units are implemented by the claim editors. They are based on the Centers for Medicare and Medicaid (CMS) MUEs, as well as Premera medical and payment policies, benefits, state regulations, statutes, and provider contract language.

Providers can identify these MUEs/maximum daily units on either CPT or HCPCS procedure codes by using the C3 Claim Editor Test Tool in the Availity provider portal.