Enhanced outpatient facility editing for National Correct Coding Initiative Medically Unlikely Edits

Beginning with claims processed on and after February 17, 2024, we will update our claims editing process for outpatient facility claims by applying the Medicare National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs). NCCI edits are guidelines developed by the Centers for Medicare & Medicaid Services (CMS) to promote national correct coding based on industry standards for current coding practices.

These edits provide an opportunity to shift certain existing back-end reviews to front-end adjudication for outpatient facility claims. While this may facilitate quicker claim adjudication, it may also cause claims to deny frequency unit limits tied to MUEs if correct coding guidelines are not followed. For additional information, visit CMS.gov and select the Medically Unlikely Edits page.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.