What are the CMS, NCCI, and MUEs and how do they affect ABA billing? Let’s take a look at this aspect of ABA billing codes and how they affect 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 mean 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.
- NCCI: The National Correct Coding Initiative (NCCI) is a program that aims to help establish rules and guidelines to reduce claim errors.
- MUEs: The NCCI has developed Medically Unlikely Edits (MUE) codes which indicate the maximum number of units a rendering provider would report under most circumstances for a single patient on one 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 they adopt to follow the MUEs set by NCCI. Therefore, ABA may or may not be impacted by these MUEs.
How MUEs work
As we highlighted in our definition above, the purpose of MUEs is to set a specific value for 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 – 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. 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)
The latest quarterly updates for MUEs for Practitioner Services, Outpatient Hospital Services, and DME Supplier Services are available here.
Let an ABA billing services provider 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 for your free revenue cycle consultation at 765-628-7400 or firstname.lastname@example.org.