Missing Piece Blog

MUEs and NCCI: What are they, and how do they pertain to ABA billing?

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)

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

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.

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 today for your free revenue cycle consultation at 765-628-7400 or weare@yourmissingpiece.com.

References:

ABA Coding Coalition: https://abacodes.org/advocacy/

CMS: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE