Understanding the financial and regulatory frameworks that govern billing practices is paramount for ABA providers. For businesses seeking to enhance their billing efficiency, compliance, and, ultimately, their financial sustainability, all while continuing to deliver high-quality care to those in need, comprehensive knowledge of the services, codes, and processes involved in billing is essential.
So, what are CMS, NCCI, and MUEs, and how do they affect ABA billing? Let’s take a look at these aspects of ABA billing codes and their influence on ABA providers.
Understanding CMS, NCCI and MUEs
There are many abbreviations used by health insurers, some of which you may not have heard of. Three of these abbreviations are the CMS, NCCI, and MUE. Here is what each of these terms means and how they are connected:
CMS
The Centers for Medicare and Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services. For ABA businesses, navigating the guidance and reimbursement rates set by CMS is crucial for delivering services to a broader demographic, especially those reliant on Medicare and Medicaid. Since CMS dictates the coverage policies for treatments, compliance with their standards ensures that services provided are both accessible and affordable.
NCCI
The National Correct Coding Initiative (NCCI) was established to prevent improper payments when incorrect code combinations are submitted during the claims process. In the context of ABA services, the NCCI meaning is to highlight the importance of correct code usage to accurately describe the services provided. These codes are designed to reflect usage that is both medically necessary and within the standards set forth by the initiative.
By adhering to NCCI guidelines, ABA providers can reduce the incidence of claim rejections and ensure that they are compensated appropriately for the services rendered. Familiarity with NCCI codes and their application can significantly improve the efficiency and effectiveness of billing operations within the ABA sector.
MUE
MUE is a medical abbreviation developed by the NCCI and stands for Medically Unlikely Edits. What is an MUE? These codes indicate the maximum number of units a rendering provider would report under most circumstances for a single patient on a specific date of service. Medicare or other payers can use the framework for claims or services billed in error. Not all Current Procedural Terminology (CPT) codes have an MUE. Most payers can choose whether to follow the MUEs set by NCCI. Therefore, ABA may or may not be impacted by them.
How MUEs work
As highlighted in the above definition, the purpose of MUEs is to set a specific value regarding the acceptable number of claims for a single patient on a specific date of service or claim line. MUEs are split into three categories:
- Practitioner Services
- Outpatient Hospital Services
- DME Supplier Services
The category that applies to ABA practitioners is the practitioner services code.
When viewing MUE tables, you will find the following information:
- HCPCS Level II/CPT® codes: These are the different classes of standardized codes that are used, depending on the service provided.
- MUE values: This is the maximum number of units per claim line or date of service.
- MUE adjudication indicators (MAIs): This is the type of MUE.
- MUE rationales: This is the underlying basis for each MUE.
Most payers follow CMS MUE guidelines, but not all. If a provider submits claim lines that exceed these MUEs, the claim might pay up to the MUE amount, or it might deny the entire claim line. This results in further delays in payment and outstanding accounts receivable amounts.
Providers should evaluate their clinical and operational practices to determine what is in the best interest of the patient and their business to determine how they might modify their procedures in light of the MUEs — if at all.
The MUE adjudication indicator on these codes is three, which means you can appeal denials for exceeding the MUE. The burden of proof in these appeals is high, and your documentation must support the medical necessity of rendering more than the MUE limitation.
MUEs for the 2019 CPT® codes for adaptive behavior services
The ABA Coding Coalition has worked diligently with the NCCI to update the MUEs, with some recent success. At the time of publication, these codes remain in effect since the update on January 1, 2021.
Code Unit Limit
97151 Medicaid allows 32 units; however, Medicare still only allows 8 units, which most commercial payers follow.
97152 16 (increased from 8 units)
97153 32
97154 18 (increased from 12 units)
97155 24 (the request to increase to 32 units was denied by CMS)
97156 16
97157 16
97158 16
0362T 16 (increased from 8 units)
0373T 24
Latest MUEs
The latest quarterly updates for MUEs for Practitioner Services, Outpatient Hospital Services, and DME Supplier Services are available here.
Choose Missing Piece to handle the complexities of ABA billing
Need a partner to help you understand all the jargon and rules? Let Missing Piece Billing and Consulting help you put all the pieces together. Contact us to discover the benefits of outsourcing ABA billing. Call 765-628-7400 or email weare@yourmissingpiece.com for your free revenue cycle consultation.