Wiki What in the world does this mean??

[RaveenaS]

Can someone please tell me what this means??? BCBS is not helping at all with the explanation when only ONE doctor performed 47562. (Dx: K80.10) Patient only has ONE gallbladder, so I don't get it. I got this message back when I asked where to send my PDR. They're seriously fighting me on sending in an appeal. -_-

"Please be advised that A MUE (medically unlikely edit) for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single member on a single date of service. The MUE edits were developed based on anatomic considerations, HCPCS/CPT code descriptions, CPT coding instructions, CMS policies, nature of an analyte, the nature of a HCPCS/CPT code or service, nature of equipment, clinical judgment, prescribing information, and claims data. This HCPCS/CPT code has a MAI of “2” or “3” and is identified as a date of service edit. This claim line was recommended for denial because all occurrences of this HCPCS/CPT code exceed the HCPCS/CPT code assigned daily MUE value. Therefore, this procedure is disallowed."

 

[TThivierge]

Can someone please tell me what this means??? BCBS is not helping at all with the explanation when only ONE doctor performed 47562. (Dx: K80.10) Patient only has ONE gallbladder, so I don't get it. I got this message back when I asked where to send my PDR. They're seriously fighting me on sending in an appeal. -_-

"Please be advised that A MUE (medically unlikely edit) for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single member on a single date of service. The MUE edits were developed based on anatomic considerations, HCPCS/CPT code descriptions, CPT coding instructions, CMS policies, nature of an analyte, the nature of a HCPCS/CPT code or service, nature of equipment, clinical judgment, prescribing information, and claims data. This HCPCS/CPT code has a MAI of “2” or “3” and is identified as a date of service edit. This claim line was recommended for denial because all occurrences of this HCPCS/CPT code exceed the HCPCS/CPT code assigned daily MUE value. Therefore, this procedure is disallowed."

Hi it seems like your CPT 47562 is not matching the dx code of K80.10. Look at descriptions of the CPT and dx code. Maybe just a stone or calculus was removed not the whole gallbladder. Review the dx. and operative report . Also check out CPT code 43268 or 43265, . I hope this helps you. Insurance companies will deny if dx codes and CPT do not match. Good luck
Lady T

 

[amyjph]

Good advice above. Also, sometimes denials are so basic we get down the rabbit hole and don't notice. You may have already checked but just make sure there is no typo or error where there is more than 1 unit billed or a wrong modifier such as 50. Also, make sure if there was an assistant at surgery that the correct modifier was used and it didn't get paid accidentally as the primary surgeon's claim. I have seen errors made where the PA assistant claim goes out first missing the AS modifier or a surgeon assistant claim is missing the 80. The claim gets paid and then the actual primary surgeon claim gets denied.

Other than that, sometimes denial messages don't match the actual problem or they are misleading so you have to start with the basics and then move forward checking everything that could be wrong. DX, CPT, Mods, payment policy, payer rules, etc. Sometimes we try to appeal for the wrong reason.

 

[michellepilcher]

I have had that denial. The reasoning was another provider had attempted to do the surgery but could not complete it due to patient body size. When they billed it however, they didn't append the modifier so it looked like the surgery had been completed. I eventually got it fixed but took a while and a lot of convincing to get the previous surgeon's office to fix the issue