Medically Unlikely Edits

Medically Unlikely Edits

Medically Unlikely Edits (MUEs) are intended to flag potential fraud and/or billing errors by identifying the maximum number of units a provider is likely to report for a specific code in a single day for an individual patient. MUEs are not intended to limit medically necessary treatment, and they do not eliminate the prohibition on quantitative treatment limits established by the Mental Health Parity and Addiction Equity Act (MHPAEA).

As the CPT I codes have been adopted by insurers and health plans, some providers are experiencing claims denials (i.e., non-payment of a claim for services rendered) on the basis that a service exceeds the MUE. This is an improper basis for a claims denial, as the MUE is meant to alert the payer to potential billing errors or fraud; the MUE is not intended to prevent legitimate claims from being paid. CMS has provided clear guidance that MUE with an MUE Adjudication Indicator of 3 may be paid in excess of the MUE if services were actually provided, properly coded, and medically necessary. As noted in the table below, all CPT I codes for adaptive behavior have a MUE Adjudication Indicator of 3. Providers who encounter these claims denials are encouraged to appeal them and to report the denial(s) to ABABCC here.

ABABCC is working with health plans and insurers to fix this issue, and documentation of provider experiences will increase the effectiveness of this initiative. As always, please redact all patient PHI from any documents you share.

 

CPT Code Units Per Day MUE Adjudication Indicator* Notes
97151 32 for Medicaid 3 Medicare MUE remains at 8, and payer claims process seems to recognize Medicare MUE, rather than Medicaid MUE.
97152 8 3 ABABCC is collecting data to determine whether this MUE should be increased.
97153 32 3  
97154 12 3 CMS denied request to increase this MUE.
97155 24 3 CMS denied a request to increase this to 32.
97156 16 3  
97157 16 3  
97158 16 3  
0362T 8 3  
0373T 32 3  

*CMS has provided guidance that codes with an MUE Adjudication Indicator of 3 are not limited to the MUE when services are provided, correctly coded, and medically necessary.