What in the world are MUEs and the NCCI? The Centers for Medicare and Medicaid Services (CMS) utilizes an agency called the National Correct Coding Initiative (NCCI) to help establish rules and guidelines to reduce claim errors. The NCCI has developed Medically Unlikely Edits (MUE) that Medicare or other payers can use as the framework for claims or services billed in error. An MUE is the maximum number of units a rendering provider would report under most circumstances for a single patient on one date of service. Not all CPT codes have an MUE. Most payers can choose whether they adopt to follow the MUEs set by NCCI. Therefore, ABA may or may not be impacted by these MUEs.
The ABA Coding Coalition has worked diligently with the NCCI to update the MUEs, with some recent success. The following Medicare MUEs are in effect as of 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)
97154 18 (increased from 12 units)
97155 24 (the request to increase to 32 units was denied by CMS)
0362T 16 (increased from 8 units)
Most payers follow these Medicare 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 their business and patients to determine how they might modify their procedures in light of the MUEs — if at all.
The MUE Adjudication Indicator on these codes is 3, 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.
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ABA Coding Coalition: https://abacodes.org/advocacy/