Wiki MUE -0 for cpt 11201

[NishaJ]

Hi ...As per the cms , MUE for cpt 11201 is O, where as Medicare Part B AZ, denied 11201 with units more than 1 , and rep states only 1 units allowed per day..
here our physician removed 40 skin tags. Please advice can we bill any other way or any other modifier...
Thanks in advance

 

[CodingKing]

The one thing to remember about MUE is there are unpublished MUE's as well to prevent fraud, waste and abuse. In addition some payers have custom MUE edits For example United only pays 1 unit per day. I'm guessing an appeal with medical records will be necessary since this case would be considered an outlier, they will want to see the medical necessity as well.

 

[NishaJ]

Thank you @ Coding king , Can we try this with 59 modifier in additional line items..

 

[CodingKing]

MUE's set at a per day limits cannot be overridden by modifiers. There is no way to override it without appeal.

For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. The appropriate use of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service) will accomplish this purpose. Modifier 59 may be utilized only if no other appropriate modifier describes the service. For MUEs that are adjudicated as date of service edits, units of service (UOS) in excess of the MUE value may be paid during the appeal process. (See separate FAQ for information about date of service MUEs.)
(FAQ11352)

Modifier 59 wouldn't be the right one anyways since it doesn't meet the definition of "distinct or independent". The code is not anatomic specific, there is no separate incision, its not a separate encounter, its not per lesion code and its not a component of a separate procedure on the same day. Also modifier 59 should never be appended to a code just because it will make it pay.