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MUE and Modifier 55 - any code reported

gost

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According to CMS, "Caution: MUEs should NOT apply to any code reported with modifier 55."

I interpret this to mean any code billed with modifier 55 should not be subject to the MUE edits as long as 55 is a valid modifier for that procedure code.

A coworker interprets to mean that MUE edits are overridden for any code billed with modifier 55 and that Medicare/Medicaid payers must allow the modifier with any code, even in modifier 55 is not a valid modifier for that code.

So far, I have been unable to get clarification from CMS. Anyone been through this and already have a response? Any opinions?

I wasn't sure which forum to post this in so it's in several. Sorry for the redundancy.
 

mitchellde

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OF course it is logical and they do not have to spell it out that the 55 modifier must be used properly or you will get not an MUE edit but an invalid modifier edit. They did not say that edit would not apply!
 

gost

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Thanks Debra. I agree. It seems obvious to me. Unfortunately, this coworker argues that denying the line as an invalid modifier would be in violation of the MUE rules. It's also unfortunate that she is the one who will make the decision. I forsee trouble on our horizon...
 

mitchellde

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Oh My! You do have a problem then.. so she thinks you can then put a 55 on every code to bypass all edits? That is pardon me but ludicrous, then what would be the point of other modifiers and edits. I see many denials in your future. I am sorry I am unable to give you any better logic or resources.
 

gost

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:D I received a clarification from CMS today. They respond:

"The MUE Claims Adjudication Rules do not contain specific procedure code to modifier
linkages, as previously stated, modifiers must be used appropriately per CMS instructions
and the information from the CPT Manual and HCPCS Manual. CMS expects States and
AB/MACs to have local edits that would compare the procedure code and modifier to
ensure they are compatible. In your scenarios above, because modifier 55 is for use only
with surgical codes that have a postoperative management component, it is not
appropriate for use with a physical therapy code such as 97010 or a DME code such as
E0607, the claim should be denied."

And I am vindicated. :cool:
 
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