I recently billed an extended ophthalmoscopy to Blue Cross. What does this have to do with the Medicare Unlikely Edits you ask? Not much, just an intro. If you want to get right into it, skip down to the second paragraph. OK, back to the story. As those of you who bill for an ophthalmologist know, we used two line items of the 92225 with the RT/LT modifiers. Blue Cross paid the 92225 RT but denied my charge for the 92225 LT stating that according to the Medicare Unlikely Edits, only one unit of that code was allowed per day.
OK. Two things.
- Why is it ALWAYS Blue Cross? Seriously, Aetna doesn’t give me these kinds of problems.
- I am 100% sure that the Medicare Unlikely Edits realize that people have TWO eyes and TWO units of that code are allowed per day. Now I need to look up the table, verify that information, and deconstruct the CMS terminology to write my appeal letter.
The Medicare Unlikely Edits (MUE) are a table of guidelines that CMS puts out to indicate how many units of any given service are allowed for a single date of service. Here is a link to the MUE page on the CMS site. And, to make your life much easier, here is the MUE Table. The table has the CPT/HCPCS code in the first column, the Practicioner Services MUE Values in the second column, the MUE adjudication indicator in the third column, and the “MUE Rationale” in the fourth column. There is a fair amount of terminology that CMS made up specifically for these guidelines, and there is a PDF file 43 pages long that explains what that terminology means. But I am going to give you the cliff notes version, directly from the CMS manual.
Practicioner Services MUE Values = Maximum number of units allowable for a single beneficiary on a single date of service.
MUE adjudication indicator = Claim line or date of service edit. 1 = claim line edit, 2 & 3 = DOS edit.
- A claim line edit means that appropriate modifiers ( e.g. 59, 76, 77, 91, anatomic) can be used to report the same code on separate lines of the claim. Example: A patient is in the emergency room with an asthma attack and he gets a breathing treatment. You use 94644 for the first hour, and up to two units of 94645 for the next two hours and the patient is no longer wheezing. However, before being discharged, he starts having another attack. You bill an additional line item of 94645 with the 76 or 77 modifiers with up to two additional units.
- Indicator 2 means that there is no situation ever in which more than the indicated number of units would ever be payable. For example, in my situation, the code 92225 has an indicator of two. That is because every person in the world has a maximum of two eyes and there is no situation in which an insurance would need to pay for more than two units for a single patient one one visit.
- Indicator 3 means that it is “possible but medically highly unlikely that higher values would represent correctly reported medically necessary services.” So, you do have some room to appeal with these codes if you can prove the services were medically necessary.
MUE Rationale = The criteria CMS used to determine the number of units allowed for each service. **Warning* Giant list of terminology ahead**
- Anatomic considerations – A limit on the number of units based on anatomic structures. Ex: CPT 24357 – Tenotomy of the elbow, This code has a max of two units allowable, because each person has a max of two elbows.
- Code descriptor/CPT Instruction – A limit on the number of units based on coding instructions directly from the CPT manual. Ex: CPT 73565. The CPT description says “Radiologic examination, knee; both knees, standing, anteroposterior” and the total number of units allowed is one. The one code already includes both knees for a single unit, so no additional units are payable. Unless the test had to be re-done for some medically necessary reason. Which you would then have to prove.
- CMS Policy – A limit on the number of units based on established CMS guidelines. Those policies and guidelines can be found on the Medicare Coverage Database
- Nature of an analyte – A limit on the number of units based on one of the following three factors:
- The nature of the specimen may limit the units of service – Ex: a test requiring a 24-hour urine specimen
- The nature of the test may limit the units of service – Ex: a test that requires 24 hours to perform.
- The physiology, pathophysiology, or clinical application of the analyte is such that a maximum unit of service
for a single date of service can be determined. Ex: the MUE for RBC folic acid level is one since the test would only be necessary once on a single date of service.
- Nature of service/procedure – A limit on the units of service, determined in general by the amount of time required to perform a service. Ex: an overnight sleep study
- Nature of equipment – A limit on the units of service, determined in general by the number of items of equipment that would be utliized. Ex: cochlear implants
So, when I look up the code 92225 here is what I see:
CPT MUE Values MUE Adjudication Indicator MUE Rationale
92225 2 2 Date of Service Edit: Policy CMS Policy
This means that for CPT code 92225 a provider can bill two units of the service, and that is per CMS policy. So, now I can write an appeal to Blue Cross, with a copy of that line of the table, and a letter stating “As you can see, per CMS policy, two units of 92225 are reasonable and customary. Since you are adhering to the Medicare Unlikely Edits, please reprocess and pay line item 92225 LT.”
I hope you can use this as an additional weapon in our never ending war against the insurance companies. As always, if you need any additional help, want to set up a training for your office, or are so touched by my helpfulness and eloquence that you would like to thank me personally (j/k) please call (909) 374-5439 or email firstname.lastname@example.org.