Tag Archives: Appeal

Medicare Unlikely Edits – or – The Rules Private Insurances Quote to Deny Your Claims

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.

  1. Why is it ALWAYS Blue Cross? Seriously, Aetna doesn’t give me these kinds of problems.
  2. 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:
    1. The nature of the specimen may limit the units of service – Ex: a test requiring a 24-hour urine specimen
    2. The nature of the test may limit the units of service – Ex: a test that requires 24 hours to perform.
    3. 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 newgenerationbilling@gmail.com.

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The insurance denied your claim, now what?

Today we are going to play Unpleasant Truth Time. All those rules that you painstakingly memorized to get your claims out of the door are just the beginning. Insurance companies have more reasons to deny your claims then I could even begin to list here, and the biggest and most time consuming part of your job will be to unravel those reasons and get your doctor her money. This post will help you to do that. Email me at newgenerationbilling.com for the Cliff Notes version of this post.

There are two kinds of follow up–loose paper follow up and insurance aging follow up. Your loose papers are denials, partial payments, and requests for information from the insurance companies. Even with a healthy account you are going to have your share of these.

When you have denied and partially paid charges, here are your options to get them paid:

1. Resubmission

2. Reprocessing

3. Appealing to the insurance company

4. Appealing to  the insurance commissioner

When you resubmit a claim it is usually to correct an error. When I get a denial from an insurance company, the first thing I do is to make sure that I billed everything correctly, even though I have been doing this for over a decade now. And I make sure to check EVERYTHING. I review the diagnosis, service, date, doctor, facility, insurance, and id#, because these are all things  I have messed up on in the past. Just a quick aside for those of you who are planning on calling us for billing or consulting services, please be assured, those mistakes are very rare. If I was the kind of person to use a smiley face in my professional blog, I would put one here.

When you do make a mistake all you have to do is correct the claim and mark in box 19 that this is a corrected claim and indicate what you fixed. Here is an example. Say you billed a DX of 627.9 (postmenopausal syndrome) to a Mr. Henry Winkler. Now, Mister  Henry Winkler is not going to have postmenopausal syndrome because he is a man. You pull up the superbill and realize that you meant to bill 682.9 (cellulitis). Change your ICD9 code, in box 19 write “Corrected claim, Corrected ICD9 code”, and resubmit your claim.

Most of the denials you receive, however, will not be your fault. This is where you would call the insurance and have them reprocess the claim. Insurance companies process claims wrong all the time. Several times I have even had my claims denied as duplicates to themselves! If the claim was denied due to an error on the part of the insurance, usually all we have to do is call them and get them to send the claim back for reprocessing. Make sure you have the following information available when you call because it will save you a great deal of stress:

1. Your provider’s NPI and Tax ID. They don’t always ask for both of these, but having them in front of you when you do your follow up will save you time with those representatives that do want both numbers.

2. The patient’s ID number, name, and date of birth. They always ask for all three of these things. When you’re on the phone with an insurance company, the rep won’t hurry you, or tell you that you’re wasting her time, or ask you to hang up and call back once you have the information. But if you are scrambling around for it, you are wasting your own time.

3. The date of the charge you are calling in regards to, and total billed amount of the charge. The insurance is going to have a lot of claims on file, so they are going to need the amount of your claim to make sure the two of you are talking about the same thing.

When you request that a claim be reprocessed, please don’t take no for an answer. If the claims representative won’t help you, go up to a supervisor. Hang up and call again. Since you’ve already checked your claim top to bottom, you know that the error was not on your side and you should not have to take any more of your time to resolve this issue.

You will run across things that a phone call cannot resolve. In those cases, we send in written appeals. With my appeals I send a copy of the claim, any documentation I have to support my position, and a letter. In my letter I  explain exactly what my objection is, what documentation I am attaching, and what result I expect to see. Here is a sample Appeal letter for something like a timely filing. I keep templates of my letters on file for the most common denials: timeliness, medical necessity, incorrect duplicate denials. If you want, I can post samples of those as well, just email or comment and I’ll put them up.

Now, no matter how exactly worded your letter, and no matter how thorough your documentation, sometimes your appeals will be denied. Your last resort is to go to the insurance commissioner. You can see your options on the state website http://www.insurance.ca.gov/  and there are step by step instructions on how to file your complaint.

Once all the loose papers on your desk have been taken care of, it is vital that you pull an aging report. The claims that get denied and partially paid are the claims the insurance receives. If you read the appeal letter, you probably realize that many of the outstanding claims you have on your accounts receivable right now are claims that the insurance has “never received.” The insurance will never send you a zero dollar EOB or a request for information, and your time limit to file and to appeal will run out before you realize.

Doctors, office managers, billers, please remember to pull your aging on a monthly basis. Not only will you catch the follow up that you would not otherwise find, you can make sure that your aging is healthy. A healthy aging will have at least 80% of your outstanding balances within 60 days. We have customers with 90% of the charges outstanding within 60 days.

If you pull your aging and you don’t like what you see, that is where New Generation comes in. Call us at (909) 374-5439 or email us at newgenerationbilling.com. You have plenty of options, call us and find out what the are.

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Filed under Accounts receivable, Billing, Claims, Denials, Doctor's Office, Follow up, Health Care, Medical Billing, Office policy