Wiki Medicare Denying Excisional Debridement

[tng141@aol.com]

One of our doctors recently saw a patient at the hospital and had to do an excisional debridement of the right buttock/groin. The total square cm is 374. My coder coded 11046 with 18 units.
Medicare is denying this CPT code because it does not support this many frequencies. I was told Medicare will only pay for 5 units. Has anyone had this issue before? If so did you send an appeal with all documentation showing why we put 18 units or do you only put the number of units Medicare will pay?

Thank You!

 

[csperoni]

This is about MUE (medical unlikely edits). MUEs are there to indicate something is "unlikely" but not impossible. I suggest:
1) confirm your size and that someone didn't move a decimal or convert mm to cm incorrectly.
2) Make sure you also billed the primary code for add on 11046
Exceeding MUEs typically requires an appeal to pay for additional units beyond standard allowed units. Some MACs are more flexible than others with MUE overages.

You may want to consider billing this claim as 3 lines:
1) Primary debride CPT
2) 11046 for maximum allowed MUE
3) 11046 for additional beyond MUE
Some coders suggest this method so that on the initial submission, you will at least get payment for some of the work, and will only need to appeal the MUE exceeded amount. Billing 11046 with 18 units will result in a denial of all units.
PS - Codify is listing 10 MUE for 11046 for practitioner services. You may want to confirm the MUE for 11046 as 5.