Updated for Quarter 3, 2021
Medicare Part B (outpatient) and Medicaid use Medically Unlikely Edits (MUEs), a subset of the National Correct Coding Initiative (NCCI), to determine same-day billing limits for individual procedure and device codes. This page provides information on Medicare MUEs for audiology services in outpatient settings.
The Centers for Medicare & Medicaid Services (CMS) developed the MUEs for use on all Medicare Part B claims. An MUE for a Current Procedural Terminology (CPT® American Medical Association) or Healthcare Common Procedure Coding System (HCPCS) Level II (supplies, equipment, devices, and some procedures) code specifies the maximum number of times that the code can be reported by an individual provider for the same patient on the same day. They include edits for provider-based services provided in clinics, private practices, and physician offices, and edits for outpatient hospital and other facility-based services, including skilled nursing facilities, comprehensive outpatient rehabilitation facilities, and certain home health services.
Medicaid MUEs are not captured here but are listed on the CMS website. State Medicaid agencies may modify the MUEs to meet their own programmatic needs and other third-party payers may also adopt them. Please check with non-Medicare payers regarding their use of MUEs.
Audiologists should also be aware of CCI edit restrictions, which control specific code pairs that can be reported by an individual provider on the same day for the same patient.
Please see ASHA's overview of the NCCI system for additional information and resources, including appropriate use of modifiers. Audiologists should also review Chapter 1 of the official NCCI Policy Manual for detailed guidance from CMS.
CMS updates MUEs quarterly.
Audiologists should check this resource regularly because CMS makes quarterly updates, beginning on January 1 of each year. ASHA reviews the changes and makes updates to the audiology tables, as needed. The July 2021 quarterly updates did not include changes to audiology related MUEs.
MUEs should apply to the provider, not the facility or office where services were provided.
According to CMS's NCCI FAQs, each MUE applies when reported by the same provider/supplier, for the same patient on the same date of service. This may be complicated when billing under a clinic or facility's group number. Be sure the rendering provider's information is associated with each CPT code on the claim to avoid potential denials based on MUEs.
Most codes commonly billed by audiologists have an MUE of “1”.
Most audiology codes have an MUE of “1” because they are untimed, meaning that they can be billed only once per date of service, regardless of the length of the procedure. However, timed codes will generally have an MUE greater than “1” because they are meant to be billed in multiple units to capture the specific amount of time spent on that procedure. For example, CPT code 92620 (central auditory processing evaluation, first hour) has an MUE of 1 because it may only be reported once, but its add-on code, 92621 (each additional 15 minutes), has an office-based MUE of 2. This means that an audiologist in an outpatient office or clinic setting can be paid for a maximum of an hour and 30 minutes of evaluation time.
Not all codes have an MUE.
Not all codes have an MUE. If you don't see an MUE for an audiology-related code listed here, it means it isn’t subject MUE limits. However, keep in mind that the NCCI system doesn't include all possible combinations of correct coding edits. You are obligated to code correctly even if edits don't exist to limit billing.
ASHA derived the following tables for Medicare Part B audiology related MUEs from the complete lists of edits published on the CMS website. ASHA reviews CMS's quarterly updates and makes changes, as needed.
Column 1 lists the audiology related CPT or HCPCS code.
Column 2 lists how many units of service (UOS) are allowed for the code in a provider-based office setting.
Column 3 lists the UOS allowed for the code in an outpatient hospital or other facility-based setting.
Column 4 (Table 2 only) lists the UOS allowed for durable medical equipment (DME) provided by DME suppliers.
Note: Not all codes have an MUE. Audiology related CPT and HCPCS Level II codes are listed here only if they have an associated MUE. This not a comprehensive list, though every attempt has been made to include codes typically billed by audiologists. A complete list of MUEs is available on the CMS website. In addition, not all codes included in this list are covered by Medicare when provided by an audiologist (cerumen management, for example). ASHA includes some MUEs for informational purposes, as other payers may follow them. For more information on covered Medicare services, see ASHA’s CPT coding rules for audiologists.
Note: Quarterly MUE changes are bolded in the table. There are no changes in this table for Q3.
|CPT Code||MUE Values (Units of Service)|
|Office Setting||Outpatient Hospital & Facility-Based Settings|
HCPCS Level II codes are required for claims for supplies and devices typically billed through DME contractors (e.g., implantable hearing devices and related equipment). Hearing aids are not included on this list because they are not covered under the Medicare benefit. Additionally, Medicare does not cover routine physical checkups for the purposes of prescribing, fitting, or changing hearing aids or examinations for hearing aids.
Note: Quarterly MUE updates are bolded in the table. There are no changes in this table for Q3.
|HCPCS Code||MUE Values|
|Office Setting||Outpatient Hospital & Facility-Based Settings||DME Supplier|
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