NCAAS is pleased to announce that CMS has increased the Medically Unlikely Edits for three of the adaptive behavior codes: 97152 (increased from 8 to 16 units); 97154 (increased from 12 to 18 units); and 0362T (increased from 8 to 16 units). NCAAS continues to work with CMS to increase the MUE for 97151. Although the MUE on the Medicaid side is 32 units, it remains at 8 units for Medicare, and insurers’ claim processing predominantly defaults to Medicare MUE.
All CPT I adaptive behavior codes have an MUE Adjudication Indicator of 3, which means that all claims in excess of the MUE should be paid when services are properly coded, medically necessary, and rendered. 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. Providers who encounter these claims denials are encouraged to appeal them and to report the denial(s) to ABA Billing Codes Commission here.