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