Let’s Talk Medically Unlikely Edits May 2026

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Published 2026-09-09 · 24 slides · 0 views

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Let’s Talk Medically Unlikely Edits May 2026

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Description

Lets Talk Medically Unlikely Edits May 2026 Objective Agenda Objective: To help you understand the CMS files. Agenda Explain what the edits are Show you how to find and read the files Answer your questions Review the legal disclaimers at

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Let’s Talk Medically Unlikely Edits May 2026

Objective & Agenda Objective: To help you understand the CMS files.
Agenda
Explain what the edits are
Show you how to find and read the files
Answer your questions Review the legal disclaimers at the end of the presentation.

Definition

NCCI Implemented by CMS to reduce improper payments for Part B claims
CMS posts changes to each of its published NCCI files on a quarterly basis, including
Additions
Deletions
Revisions CMS Medicare National Correct Coding Initiative (NCCI) Edits webpage

MUEs Edits used by during Part B claims processing
Maximum units of service a provider reports under most circumstances for a single beneficiary on a single date of service
MACs may have units of service edits that are more restrictive
CMS website for a list
Not released all edits are public CMS Medicare NCCI Medically Unlikely Edits (MUEs) webpage

Considerations Developed based on:
Procedure code descriptor
CPT coding instructions
Anatomic considerations
CMS policies
Clinical judgment Developed based on:
Nature of serviced or procedure
Nature of analyte
Nature of equipment
Prescribing information

MUE Tables 3 separate table
Practitioner MUEs
Edits apply to all physician submitted claims
Durable Medical Equipment (DME) Supplier MUEs
Edits apply to claims submitted to DME MACs
Includes HCPCS A-B and E-V codes and HCPCS codes under DME MAC jurisdiction
Facility Outpatient Hospital Services MUEs
Edits apply to all claims for with Type of Bills 13X, 14X, 85X, and 87X

Explanation – Columns A, B, C, and D Column A – HCPCS/CPT Code
Shows procedure codes
Column B – Practitioner Services MUE Values
Max UOS reported under most circumstances
Single patient on a single date of service.
Column C – MAI
MUE adjudication level
Column D – MUE Rationale
MUE rationale category

MUE Adjudication Indicators (MAI) Assigned to procedure code
MAI 1 – value adjudicated by claims processing systems at claim line level
MAI 2 – absolute date of service edit based on policy, such as anatomic considerations, definition of the code, or published CMS policy
MAI 3 – value adjudicated by claims processing systems at the date of service level
May pay on appeal

Using the Files

Location Navigate
CMS Website
Medicare
Coding and Billing
National Correct Coding Initiative (NCCI) Edits
Medicare NCCI Medically Unlikely Edits (MUEs)
Choose your file

Example 1 Patient presents for AWV and it takes longer to perform than expected
Can you quantity bill? Look up codes
G0438 – Initial visit
G0439 – Subsequent annual visits Use the practitioner edits

Example 2 Patient presents for CVD IBT and it takes 45 to complete the service
Can you quantity bill? Look up codes
G0446 – Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes Use the Facility Outpatient Hospital Services

Example 3 IONM performed by a physician, with undivided attention to a single patient
Time spent 71 minutes
Is this quantity billable Procedure code: G0453
What’s the MUE?
How many can you bill?
Bill per 15-minute unit
At least 8 minutes of monitoring to qualify for one unit Use the Facility Outpatient Hospital Services

Example 4 Can we quantity bill G0514?
Time spent 120 minutes
Is this quantity billable? Procedure code: G0514
What’s the MUE?
How many can you bill?
Bill per 30-minute unit
Bill the primary code G0513 with 1 unit Use the practitioner edits

Resources

Policy Manual CMS Manual
Tool for correct coding
Explains rationale for NCCI edits
CMS updates this once a year
Most current manual effective 01/01/26
PDF version additions and revisions appear in red font CMS Medicare NCCI Policy Manual webpage

FAQs Basic information
Modifier help
ABN information
Requesting a change

Medicare Learning Network Revised Modification to the Medically Unlikely Edit (MUE) Program
MM8853
Proper Use of Modifiers 59, XE, XP, XS & XU
MLN1783722

Registration Questions and Answers

Chat Questions and Answers

Survey Let us know what you think!
Take time to complete our survey now.
Survey link in chat
Redirect after closing webinar

Thanks for attending!

Disclaimers This material is a tool to assist the provider community. Medicare rules change often. Access CMS’ website for current coverage, regulations and rulings.
The basis for answers given today rely on facts given in the question. Medicare rules determine final coverage.
Do not record the event as CMS does not allow this for profit making purposes.

Let’s Talk Medically Unlikely Edits May 2026

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