It's the adjudication indicator. The MUE is still 1, but the MAI went from 2 to 3.
Yes, that AAOS press release was the one I was referring to. I did see the MAI went from 2 to 3.Yep. It looks like AAOS asked for the MUE to be updated, but instead the adjudication indicator was updated from 2 to 3. (Which I guess at least gives the ability to appeal, even though it wasn't the unit update that AAOS asked for.)
BTW - when I did a quick google search, I did find this press release where AAOS had requested the unit update. If you've stumbled across this, I can see where it would be confusing and seem like CMS was going to update the MUE units:
I did appeal it and they still denied it (BCBS) I am going to Appeal again and use some of the verbiage you used, if you don't mind.You have to appeal the additional unit. It changed to MAI 3. It's not just going to be automatically paid.
https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-faq-library#muehttps://www.cms.gov/files/document/revised-modification-medically-unlikely-edit-mue-program-mm8853.pdfMUEs for HCPCS codes with a 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”. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs 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 did two separate lines with one unit per line and a 59 on the second one. I will try adding mod 22 (and deleting the 2nd line) if it gets denied again. I did see that mentioned somewhere in my reading. Thanks for your help!Also, did you bill it on two lines with one unit per line or one line with two units? I assume two separate lines with one unit since you said you appended a 59.
If that doesn't work another option *might* be apending a 22 to the one unit of 28300 if the documentation supports osteotomy being done at two separate spots on the calcaneus to correct.
Thanks for the info. I used to only bill it one time until we had our billing and coding update training in December hosted by Decision Health. They are the ones who said it is now billable twice. But since I'm seeing a denial every time I bill it twice, I am in agreement with you. Thanks for you insight!Kelly, the MUE remains at only one. The references are incorrect or perhaps the recommendation was never enacted. It CAN be billed bilateral, however, on one line with 50 modifier, 1 unit and double the price. If there were 2 osteotomy surgical fractures performed on the same calcaneus in different areas of the calcaneus, that is billed just one time with one code. No amount of rebilling with modifier 59, nor any of the other recommended scenarios will get 2 units paid on the same DOS. Modifier 22 is not appropriate, either, in my opinion.
I wasn't able to open the article either. I did go ahead and send a 2nd appeal yesterday with some info regarding the MAI of 3 etc. I code for a surgeon who does only feet/ankles and he does 28300 a lot. When we had our coding updates training in December my boss even made a point of saying how this doctor would be so happy that I can now code it twice.Good feedback Tonia. I haven't seen anything about the next quarter MUE updates. Doubtful it will be updated to 2 at the next release.
I agree the MUE is only one, but the MAI was changed and according to CMS: "MUEs for HCPCS codes with a MAI of “3” are date of service edits. These are “per day edits based on clinical benchmarks”. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs 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'm not saying it will work, but it is "possible" according to that. The documentation would have to be bullet-proof and that's a lot of "if's" above. I would be interested to know if anyone has ever successfully done this. I never have. It's the if, when, but, except, and, of coding lol
I also agree it's highly doubtful to impossible it will pay for more than 1 unit, unless bilateral. I don't think I have ever seen bilateral 28300 because the patient probably wouldn't be able to ambulate after. Has anyone ever seen a bilateral 28300?
Agree that bilateral would be billed one unit, one line, 50 mod however, there are some (random) payers that accept/require two lines RT/LT. The 50 mod one unit way is best generally though. Example: https://www.brainshark.com/1/player/humana?fb=0&r3f1=&custom=bilateralv3
Example: TX Medicaid https://www.tmhp.com/sites/default/...3/2023-04-april/2_Med_Specs_and_Phys_Srvs.pdf "220.127.116.11 Bilateral Procedures When a bilateral procedure is performed and an appropriate bilateral code is not available, a unilateral code must be used. The unilateral code must be billed twice with a quantity of 1 for each code. For all procedures, use modifiers LT (left) and RT (right) as appropriate."
A 22 may not be applicable in the case discussed here but there are times when it might be. Again, the documentation would have to support it and be explicitly clear to justify significantly greater effort, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical/mental effort required, than usual.
Additionally, unless your practice and providers are high volume for this and big reconstruction/deformity cases, is it worth all the extra time and effort to try only to be denied anyway? I would probably run a CPT report to see how many times 28300 was billed in a recent timeframe. It may not be worth pursuing aggresively if resources are limited and coding/AR time is better spent somewhere else. I know providers want us to fight for every penny but sometimes that's just not gonna happen with people resources vs. volume.
I would love to read the article in the April 22 issue of AAOS now but can't access. Anyone have it? https://www.aaos.org/aaosnow/2022/apr/managing/managing01/