How many MUE's can be billed in a day?

Both Medicare and Medicaid have national “medically unlikely edits” (MUEs) in place that are designed to automatically deny claims that exceed specific daily limits. Although these MUEs have been in place for some time, some Medicaid plans are only now beginning to implement them. MUEs should not be confused with annual utilization limits that we have seen from many commercial payers.  

For many years, the MUEs were confidential and were not published. But a couple of years ago, CMS decided they should be made publically available. Although we have published them before and they have not changed, we thought this would be a good time for a reminder.

CodeDescriptionMedicare and Medicaid MUE
95004Subcutaneous skin tests/allergenic extracts80
95012Expired Nitric Oxide2
95017Venom skin testing27
95018Skin testing for drugs and biologicals19
95024Intracutaneous tests/allergenic extracts40
95027Intracutaneous sequential and incremental90
95028Intracutaneous/allergenic extracts/delayed reaction30
95044Patch test80
95076Ingestion challenge/initial 120 minutes1
95079Ingestion challenge/each additional hour2
95144Allergy immunotherapy /single dose vials30
95145Venom immunotherapy/1 venom10
95146Venom immunotherapy/2 venoms10
95147Venom immunotherapy/3 venoms10
95148Venom immunotherapy/4 venoms10
95149Venom immunotherapy/5 venoms10
95165Allergen immunotherapy/multi-dose vials30
95170Allergen immunotherapy/whole body extract10
95180Rapid desensitization/each hour6

 

For example, if you bill Medicare or Medicaid for more than 80 skin tests on a given day, you may receive a denial. Likewise, a claim with more than 30 doses of allergen immunotherapy (95165) may also trigger a denial. You may want to be aware of these limits when billing Medicare and Medicaid.

It is also important to remember that, for payment purposes, Medicare defines a dose of allergen immunotherapy as one cc of extract. Because Medicaid is a state program, policies vary from state to state. If your state Medicaid plan adopts the same policy on definition of a dose as Medicare, the Advocacy Council may be able to provide guidance for a discussion with Medicaid payers.

For more information on CPT 95165, join our webinar – Everything you wanted to know about 95165 – on Feb. 20 at 7:30 pm CT. 

Advocacy Issue: 
Mixing Allergen Extracts
Billing, Coding & Payments