APMA News - July/August 2018 - 24

Reimbursement
By David J. Freedman, DPM, CPC

Your Coding Questions Answered
In CMS's infinite wisdom, for the better part of
the past 16 years, it has been creating Medically
Unlikely Edits (MUEs)-edits that limit the
number of times you can perform a specific
CPT code on a given date of service. CMS has
based its decision on "CMS policy" or "clinical
benchmarks." Despite APMA's efforts to be heard,
CMS has not involved our specialty in final decision-making, and only lately have these restrictions
had a larger effect on what you can bill on one date of service.
This article covers various considerations related to MUEs; for
further information, visit www.cms.gov/Medicare/Coding/
NationalCorrectCodInitEd/MUE.html.

Does every procedure I do have a limit on the number I can bill on
one given day?
Yes, it appears that each CPT code has limitations. Let's
use injections as an example. One might think there is the
same limit on any given injection CPT code, but that is not
the case. Let's look at the typical podiatric injection codes and
their MUEs. You will see in the example below the terminology "Practitioner Services MUE Values." The value reference
is the number allowed on a specific date of service.
HCPCS/
CPT Code

Practitioner Services
MUE Values

20600
20605
20550
20551
64450
64455
64632
64640

6
2
5
5
10
1
1
5

24 APMA News July/August 2018

Why would I be denied for doing a fusion on the great toe of the left
foot and the right foot on the same date?
Let's look at the code, CPT 28755 Arthrodesis great toe;
interphalangeal joint. It seems reasonable to append a TA or
LT for the one foot and T5 or RT for the other foot, doesn't it?
If you decide to code this way bilaterally, you will not get
paid by Medicare or possibly by private carriers that follow
Medicare guidelines. At first, it seems reasonable to use anatomical modifiers for this CPT code. However, when looking
at CPT 28755 in the spreadsheet on the CMS website, it has
a Practitioner Services MUE Value of 1. The MAI is 2. Date of
Service Edit: Policy MUE Rationale=CMS Policy.
The Practitioner Services MUE value of 1 means only one
can be billed on a date of service. The MAI of 2 means CMS
relies on its own policy and rationale in limiting this procedure.
If this procedure is truly done bilaterally, there is one way
to be paid for this service according to bilateral rules. Because
CPT 28755 has a bilateral indicator, this procedure should
have been billed as 28755-50, and you would double the price
and bill with "1" unit, which meets the criteria for this MUE.

Can I appeal the unreasonable policy imposed by these MUEs?
You should absolutely appeal this injustice. Although the
Qualified Independent Contractors (QICs) and the Administrative Law Judges (ALJs) are not bound by sub-regulatory
guidance, they do give deference to it and should therefore be
aware that CMS considers all edits with an MAI of 2 to be firm
limits based on sub-regulatory guidance. CMS indicates some
MUE edits with an MAI of 2 may be based directly on regulation or statute. You will have to appeal this type of denial not
only to the QIC, but ultimately to an ALJ so you can be paid
for performing these procedures.

Question mark graphic by Shutterstock/Blan-k.

Clearly, not all injections are created equal. Depending
on the CPT code, the limitations imposed are based on "clinical data"-except CPT 64455 and CPT 64632, which say,
"CMS policy."
CMS also uses the abbreviation "MAI," which means MUE
Adjudication Indicator. The rules can be found at www.cms.
gov/Regulations-and-Guidance/Guidance/Transmittals/
Downloads/R1421OTN.pdf. An MAI of 2 means the per-day
limit is based on "CMS policy." An MAI of 3 means the perday limit is based on "clinical data."

How can I know I probably got hit with an MUE?
When you see a denial on your patient's EOB
from Medicare or a private payer that follows
Medicare guidelines, the remark code will reference "CO-151." This code indicates that an MUE
is the reason for the denial.
The denial code "CO-151" is defined as: "Payment adjustment because the payer deems the information submitted does not support this many/frequency of services. Start 10/31/2002; Last Modified 1/27/2008." This
definition means the frequency exceeds the total allowed on one
day, or that you billed the code more than the allowance.

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1421OTN.pdf

Table of Contents for the Digital Edition of APMA News - July/August 2018