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DME Denials

Pauline Posted Fri 13th of June, 2014 14:54:10 PM

I have been receiving denials for DME stating 'billing of this procedure code has exceeded the national correct coding initiative medically unlikely edits (MUEs) for the number of times this procedure can be billed on a date-of-service'. I called bill review and they told me that we need to be adding a modifer in addition to LT or RT. I researched the modifier GD which states: UNITS OF SERVICE EXCEEDS MEDICALLY UNLIKELY EDIT VALUE AND REPRESENTS REASONABLE AND NECESSARY SERVICES. I was wondering if you knew of a modifier I could add so we can get these paid? Thank you!

SuperCoder Answered Mon 16th of June, 2014 15:14:20 PM

Thanks for your question.

Is there a specific code that you are receiving denials for?

Pauline Posted Tue 17th of June, 2014 15:45:32 PM

The following codes were denied:

L3908-RT
L1810-LT
L0625 this was a post-op DME

Pauline Posted Thu 19th of June, 2014 18:38:02 PM

The DME codes that are being denied are:

L3908-RT
L1810-LT
L0625 this was a post-op DME

Thank you.

Pauline Posted Tue 24th of June, 2014 11:27:37 AM

I have been receiving denials for DME stating 'billing of this procedure code has exceeded the national correct coding initiative medically unlikely edits (MUEs) for the number of times this procedure can be billed on a date-of-service'. I called bill review and they told me that we need to be adding a modifer in addition to LT or RT. I researched the modifier GD which states: UNITS OF SERVICE EXCEEDS MEDICALLY UNLIKELY EDIT VALUE AND REPRESENTS REASONABLE AND NECESSARY SERVICES. I was wondering if you knew of a modifier I could add so we can get these paid? Thank you! The DME codes that are being denied are:

L3908-RT
L1810-LT
L0625 this was a post-op DME

SuperCoder Answered Wed 25th of June, 2014 06:46:03 AM

Medicare provides a HCPCS Level II modifier for a scenario such as you describe -- GD, Units of service exceed medically unlikely edit (MUE) value and represent reasonable and necessary services. It appears that this would be a great way to "override" this denial. CMS does not offer any information regarding this code except that it is informational only. There is little information that can be found regarding this modifier and even less to support that this code will actually work in this situation.

Please consider a submitting a re-determination or an appeal for this denial. Before you do please check to make sure that the correct number of units have been billed for each code. Also make sure that the patient has not already received any of the items previously. Sometimes this can also cause denials if the patient has gone elsewhere for services without your knowledge. Make sure that your provider has documented appropriate medical necessity for the services so that you can appeal your claim. Send an appeal letter with the documentation and explanation of benefits.

Hope this helps.

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