Wiki Medicare Secondary Payer & Unit Limitation

[mmart1223]

I was wondering if anyone will be able to help me with a unit limitation with Medicare as secondary payer?

Patient is 74 with Aetna as primary and Medicare as secondary.

Patient came in for Allergy testing and we billed 99204-25, 95004 (58 units), and 95024 (50 units). In most cases when Medicare is secondary, we will only bill out 40 units of 95024 to comply with the unit limitation. However, our scrubber didn't catch this one so we billed 50 units instead. Aetna processed this visit towards deductible so once the claim crossed over to Medicare, 95024 denied as exceeds MUE threshold.

I was advised by a manager to change the units to 40 and resend to Medicare but that doesn't sound quite right to me.

Can someone advise on the approach we should take to correct this?

Should we correct the claim with Aetna first so that when it crosses over, it meets Medicare guidelines?

Thank you in advance!

 

[thomas7331]

You might want to review the CMS guidelines on MUEs, or contact your Medicare contractor and discuss this with them. MUE values are not 'guidelines' and are not statutory limitations - they are edits that placed to prevent payment errors when units billed exceed an unlikely number. They aren't limitations of coverage that you are required to 'comply' with. It's not appropriate to be coding an incorrect number of units just to avoid getting around these edits. The MUE edit for CPT code 95024 is not a hard denial because it's based on clinical data and not on a limitation prescribed by the code definition or by anatomic limitations, so these should be easily overturned on appeal. If you are performing 50 units, that is what you should be billing, and you should appeal these denials through your payer's reconsideration process with documentation that supports what was done.