Wiki 3 Major joint 20610 in one day

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kphillips9

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We have a few providers that will perform multiple injections in one day for example Bilateral Knee and RT Shoulder. Medicare will pay the bilateral line then deny the third injection as missing/invalid modifier with no appeal rights. If there is a MUE of 2 for 20610 should we be performing a third injections on same day?

Example how we submit per instruction from our MAC. We have tried with just 59 , with just RT all deny the same way.

20610 -50 M17.0
20610-59 M19.011
 
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It is not a good idea to do more than 2 in one day. 20610 is MUE 2/MAI 3. Unless they are looking for XS but the 59 can take the place. However, there is no P2P edit of the code with itself, have you tried removing the 59? Most ortho providers will make the person come back for additional more than 2.

Medicare NCCI Policy Manual | CMS

www.cms.gov www.cms.gov
MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical benchmarks.”MUEs assigned an MAI of “3” are based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services. If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor 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 know Novitas is not your MAC but this is a good explanation of MUE/MAI:

Medically Unlikely Edits

www.novitas-solutions.com www.novitas-solutions.com
MAI of “3”
MUEs for HCPCS codes with a MAI of “3” are date of service edits
These are “per day edits based on clinical benchmarks”
Appealed additional units are considered if there is adequate documentation of medical necessity to support reported units

Check out 4 MUE Facts That Will Help You Avoid Denials : Coding Edits

Some coders remain confused about medically unlikely edits — but that’s about to change. If your ENT practice receives denials from your Part B MACs for undetermined reasons, one possibility is that you’re running up against medically unlikely edits (MUEs). The edits, which are designed to...
www.aapc.com www.aapc.com
 
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The denials are from Novitas. I agree with the MUE information I was trying to get appropriate denial to share with the providers. They are giving us inconsistent modifier and we have tried like this 20610-50 M17.0 and 20610-59-RT M19.011 and 3rd injection as 26010 without the RT per instruction from Novitas.
 
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kphillips9 said:
The denials are from Novitas. I agree with the MUE information I was trying to get appropriate denial to share with the providers. They are giving us inconsistent modifier and we have tried like this 20610-50 M17.0 and 20610-59-RT M19.011 and 3rd injection as 26010 without the RT per instruction from Novitas.
Click to expand...
How many units are you putting on the bilateral line? It should only be 1 unit not 2.

According to the information on MUE/MAI you should be able to get a decision on it. "If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor 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."

Example 3:
An arthrocentesis (20600) was performed on the right and left index fingers and the right thumb.
Correct coding 1
Date of serviceProcedure codeModifierUnits
7/1/202020600501
7/1/202020600F51
 
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I have a general question/comment about codes with MAI of 3. For example, a lab code 83520. Has a MUE of 9 with MAI of 3. Is this saying that with appropriate documentation billing 12 units of 83520 (cytokine panel) does NOT need a 59 modifier to show as distinct since there is documentation to support? Or is it saying that still a 59 modifier is required for the units above 9? I understand the difference between the 1,2 & 3 MAI, I just can't get any concrete information on whether a modifier is required with MAI of 3 when above the MUE. Any help is appreciated! I have posted this general question before with no response :)
 
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