Question 11305 being billed 7 times on one claim

[sfbug23]

Question is there another way to get this claim paid by Medicare? I have a doc is billing a bx for 7 sites and Medicare always comes back and pays for one or two 11305 and then denies the rest.

 

[CBLENNIE]

I just checked the NCCI MUE table for 11305 and it shows that 4 units are allowed per DOS with a MUE adjudication indicator (MAI) of 3. Per MLN Matters # MM8853 Revised Modification to the Medically Unlikely Edit (MUE) Program MUEs for codes w/a MAI of 3 are a DOS edit. The document goes on to state:

These are “per day edits based on clinical benchmarks”. If claim denials based on these edits are appealed, 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.​

I would suggest reviewing this document and the information regarding codes with an MAI of 3 so you can appeal any claims where only 1 or 2 units were allowed when the MUEs for the code for the DOS is 4 units. Those should be the easier appeals to tackle and hopefully win. As for any claims where units in excess of 4 were denied you can appeal those as well and this document will hopefully help you have the information you necessary to successfully appeal the denied units.