ABA Coding Coalition Urges Utilization of Medicaid MUEs for Adaptive-Behavior (ABA) Services

July 6, 2020

Medically unlikely edits (MUEs) are guidelines regarding the maximum per-patient, per-day units of service for health-insurance billing codes. These guidelines are issued by the National Correct Coding Initiative (NCCI) for the Centers for Medicare and Medicaid Services (CMS) to ensure appropriate utilization of medical services. CMS publishes two separate MUE data files each quarter containing the MUEs for all healthcare billing codes, one for Medicare and one for Medicaid. These two data files sometimes provide discrepant MUE values for a given CPT code. For instance, for CPT code 97151 the current Medicare MUE is 8 units per day, whereas the Medicaid MUE is 32 units per day. Of these two MUE values, the one published by Medicaid is clearly the more appropriate MUE for the 97151 code.

Many payers adopt the Medicare MUEs, but because the vast majority of the patients served by ABA providers at this time are Medicaid rather than Medicare beneficiaries, the Medicaid MUEs are more appropriate for the CPT codes for adaptive-behavior (ABA) services. Therefore, the ABA Coding Coalition urges providers and payers to become familiar with and adopt the Medicaid MUE values assigned to the adaptive-behavior service codes. The current MUEs for a specific code can be found here by entering the code in the search box that says, “Find in this Dataset”. Our coalition will continue to advocate with CMS to increase Medicare MUEs for the adaptive-behavior-service codes that are overly restrictive, and we will provide updates regarding these MUEs as they become available.