Understand This MUE and How to Override It
Question: Our provider ordered 180 mg of lanreotide on the same date of service (DOS) for a Medicare patient, which has a Medically Unlikely Edit (MUE) of 120 mg. How should I submit a claim for this drug, and if the claim gets denied, how should I appeal? AAPC Forum Participant Answer: You are correct in saying that the outpatient hospital services MUE value for J1930 (Injection, lanreotide, 1 mg) is 120, according to the Facility Outpatient Hospital Services MUE Table available from the Centers for Medicare & Medicaid Services (CMS) MUE website. According to that same website, “An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT® code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.” The rationale given for the MUE in the table is “Prescribing Information,” which is consistent with the prescribing dosage and administration information provided by both the manufacturer and the U.S. Food & Drug Administration (FDA). However, the drug has an MUE Adjudication Indicator (MAI) of 3. These edits, Medicare Learning Network Matters publication MM8853, are “per day edits based on clinical benchmarks.” The publication goes on the note that Medicare Administrative Contractors (MACs) “may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal.” In other words, your MAC may approve the claim even though it is in excess of the MUE with appropriate documentation supplied before the claim is submitted, though they may also deny the claim and then pay it on appeal. You do not need a modifier to override the edit. Useful tips: The Somatuline® Depot (lanreotide) Reimbursement Resource Guide provides a comprehensive, though not exhaustive, list of diagnosis codes that you can use to provide medical necessity for prescribing lanreotide, including E22.0 (Acromegaly and pituitary gigantism) and various unresectable, well- or moderately-differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) coded to C7A.01- (Malignant carcinoid tumors of the small intestine), C7A.02- (Malignant carcinoid tumors of the appendix, large intestine, and rectum), C7A.09- (Malignant carcinoid tumors of other sites), and C7B.00 (Secondary carcinoid tumors, unspecified site). Your claim should also include 96273 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) for the drug administration. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
