American Health Information Management Association (AHIMA) Certification Practice Exam

What does CMS use medically unlikely edits (MUEs) to prevent?

1. Billing units of services greater than expected.

2. Inappropriate documentation in medical records.

3. Providing care that exceeds medical necessity.

4. Billing for services not rendered.

The correct answer is: Billing units of services greater than expected.

Medically Unlikely Edits (MUEs) are tools utilized by the Centers for Medicare & Medicaid Services (CMS) to prevent billing practices that seem unreasonable or exceed established limits. Specifically, MUEs are designed to identify and flag billing units of services that are greater than what is typically anticipated for specific treatment episodes or diagnoses. For example, if a medical provider submits a claim for a certain number of procedures that far exceeds a statistically based expected volume, MUEs can catch this anomaly and help to prevent potential overbilling. This focus on expected billing units ensures a level of accountability and prevents fraudulent activities that could arise from excessive claims. The other options address issues related to documentation, medical necessity, and services not rendered, but they do not align with the primary function of MUEs. Instead, MUEs specifically target the quantifiable aspect of billing units to maintain consistency and reliability in provider claims.