Medically Unlikely Edits, which are often referred to in the medical billing industry as “MUE” are used by public health institutions like the Medicare Administrative Contractors, the Durable Medical Equipment, and similar institutions to help reduce the improper payment rate for a wide range of Medicare Part B claims. An MUE for an HCPCS/CPT code is essentially the maximum number of units of service that a provider can report for a single beneficiary on a single date of service.

Though it’s important to note that not all HCPCS/CPT codes have an MUE. This has increased the need for some level of oversight or correcting mechanism to ensure accuracy throughout the Medicare system. Especially for beneficiaries who might have additional out-of-pocket expenses.

What Is The National Correct Coding Initiative?

The National Correct Coding Initiative, or NCCI, was developed by the CMS to promote national correct coding methodologies as well as to help control the type of improper coding errors that are a leading cause of inappropriate payment when processing Part B claims. The Centers for Medicare & Medicaid Services directly controls the NCCI program, which is also directly responsible for all decisions regarding its contents.

In this way, the CMS coding policies are thus based on coding conventions that have been clearly defined in the American Medical Association’s CPT Manual. This includes both national and local policies as well as common edits. All of which are coordinated by coding guidelines which have been carefully developed by national societies. It is based on careful analysis of standard medical and surgical practices, as well as an extensive review of current coding practices.

How MUEs Are Implemented?

It’s also worth noting that the CMS annually updates the National Correct Coding Initiative Policy Manual for Medicare Services. The goal is to ensure that the NCCI Policy Manual should be used by Medicare Administrative Contractors always have a general reference tool that explains the rationale for making any and all NCCI edits.

These updated codes are further implemented by the NCCI with PTP edits included in the claim processing systems. The CMS further incorporates PTP edits into its outpatient code editor (OCE) for OPPS. This also makes it easy for these edits to be applied to outpatient hospital services as well as other facility services including:

  • Approved therapy providers
  • Part B skilled nursing facilities
  • Comprehensive outpatient rehabilitation facilities
  • Outpatient physical therapy
  • Speech-language pathology providers
  • Specific home health agencies

This updated coding allows for medical billing under TOBs 22X, 23X, 75X, 74X, 34X. MACs implemented Medically Unlikely (MUE) edits and corresponding MUE edits are similarly implemented within the Fiscal Intermediary Shared System.

The Goal Or NCCI PTP Edit Codes

The overarching goal of the NCCI PTP edits is to create a management tool that prevents improper payment any time that an incorrect code combination is reported. To do this the NCCI provides one expansive table of edits that are meant to be used by physicians and practitioners as well as another table of edits for outpatient hospital services.

In this way, the NCCI’s MUE program helps to prevent improper payments when claims are reported with incorrect units of service.

A Closer Look At MUE Code Usage

The NCCI specifically developed Medically Unlikely Edits so that Medicare, other payers, and public health institutions can implement the framework for efficiently submitting and processing claims for services that might have been initially billed in error.

An MUE is technically considered to be the maximum number of units a provider can render or report under typical circumstances. It is based on a single patient for one single or a specific date of service. It’s also worth bearing in mind that not all CPT codes have an MUE. To help provide further clarity the ABA Coding Coalition has worked collaboratively with the NCCI to update the MUEs for the following codes.

Codes & Updates Unit Limits

  • 97151 this Medicaid allows 32 units. Though Medicare still only allows 8 units, which is what most commercial payers follow.
  • 97152 this code has increased to 16 units from the previous limitation of 8.
  • 97153 this updated code allows for up to 32 units.
  • 97154 the MUEs for this code has increased from 12 to 18 units
  • 97155 it’s worth noting that this code has been limited to 24 despite a request to expand it to 32.
  • 97156 this code is set at 16 units
  • 97157 this code is set at 16 units
  • 97158 this code is set at 16 units
  • 0362T This code has been increased from 8 to 16 units to meet contemporary demand.
  • 0373T has been set at a maximum of 24 units.

It’s worth bearing in mind that most payers and public health institutions follow these Medicare MUE guidelines. Though not all payers do. This means that if a provider submits claim lines that happen to exceed the allowed level of MUE units, that the claim might pay up to the MUE amount. Though in some instances the entire claim line might be denied by one of the rare payers who have yet to adopt these MUE guidelines. In a situation like this, it could result in further delays in the claims process, which could lead to a claim denial, claim rejection, or a significant delay in payment which could affect the consistency of a practice’s revenue stream.

This makes it of the utmost importance for providers to evaluate their clinical and operational practices to accurately assess what is in the best interest of their business as well as the best interests of their patients. This will go a long way toward determining how your practice might modify its procedures in light of the MUE changes.

MUE Adjudication Limits

Providers should also take into account the MUE Adjudication Indicator on the majority of these codes is 3. This essentially means you can appeal denials for exceeding the MUE. However, the direct burden of proof for these appeals is very high, and all elements of documentation must be data-driven in supporting the medical necessity of rendering more than the 3 MUE limitation.