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 speech-language pathology 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.
SLPs 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. SLPs should also review Chapter 1 of the official NCCI Policy Manual for detailed guidance from CMS.
CMS updates MUEs quarterly.
SLPs 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 speech-language pathology tables, as needed. The July 2021 quarterly updates included one change to the DME supplier MUE for HCPCS code A7525 (Tracheostomy mask, each). The MUE changed from 3 to 8 units of service.
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 SLPs have an MUE of “1”.
Most speech-language pathology 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 96125 (standardized cognitive performance testing, per hour) has an MUE of 2, meaning that an SLP in an outpatient setting can be paid for a maximum of two hours of evaluation time.
Not all codes have an MUE.
Not all codes have an MUE. If you don't see an MUE for a speech-language pathology 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 speech-language pathology 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 speech-language pathology 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. Speech-language pathology 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 SLPs. 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 SLP (certain physical medicine and rehabilitation services, 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 SLPs.
Note: Quarterly MUE changes are bolded in the table. There are no changes to this table for Q3.
|CPT Code||MUE Values (Units of Service)|
|Office Setting||Outpatient Facility Setting|
HCPCS Level II codes are required for claims for supplies, devices, and some services. Some devices may only be supplied and billed by an authorized Medicare DME supplier and are marked as "0" in the office and facility settings.
Note: Quarterly MUE changes are bolded in the table. The Q3 quarterly updates included one change to the DME supplier MUE for HCPCS code A7525 (Tracheostomy mask, each). The MUE changed from 3 to 8 units of service.
|HCPCS Code||MUE Values (Units of Service)|
|Office Setting||Outpatient Facility Setting||DME Supplier|
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