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Units

Marilyn Posted Wed 13th of February, 2019 11:18:53 AM
Practitioner billing 7units for "96152" when the daily allowed is 6units. How can the extra unit be captured? Or would this be an appeal?
SuperCoder Answered Thu 14th of February, 2019 06:44:32 AM

Hello Marilyn,

Thank you for your question.

 

Since, the MUE of CPT® code 96152 is 6, it means this service can be reported for a maximum of 6 units per day; but the MUE Adjudication Indicator (MAI) is “3”, which indicates a date of service (DOS) edit is based on clinical benchmarks. MACs may pay excess units upon appeal or may bypass the MUE based on documentation of medical necessity.

 

Hope that helps.

 

Please feel free to write if you have any question.

Thanks

Marilyn Posted Thu 14th of February, 2019 10:27:07 AM
So this means there's not even a modifier that can be used to capture the "1" unit? This is for Medicaid, MCO Blue Cross Community Medicaid.
SuperCoder Answered Fri 15th of February, 2019 01:53:18 AM

Hello Marilyn,

Thank you for posting your follow-up

 

As per CMS, MUEs for codes with a MAI of “3” will be date of service edits. These are “per day edits

based on clinical benchmarks”. If claim denials based on these edits are appealed, contractors may pay

Unit of Service (UOS) in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If contractors 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 contractor may bypass the MUE for a code with a MAI of “3” during claim processing, reopening or

redetermination, or in response to effectuation instructions from a reconsideration or higher-level appeal.

 

Also, you can append modifier GD with CPT® code 96152.

Modifier-GD states: Units of service exceeds medically unlikely edit value and represents reasonable and necessary services

 

 

Further, you are suggested to kindly check with your respective payer for reimbursement guidelines for exceeding MUE.

 

 

Hope that helps.

 

Please feel free to write if you have any question.

Thanks

Marilyn Posted Fri 15th of February, 2019 14:14:14 PM
Say 96152 is 6u/day. The exceed is 2units, will the claim be broken down as: 96152 x 6, 96152-GD x 2 or just one line item with the modifier"GD".
SuperCoder Answered Mon 18th of February, 2019 03:53:30 AM

Hello Marilyn,

Thank you for posting your follow-up.

 

You can report CPT® code 96152 on a single claim line with modifier GD and appropriate units.

Your medical documentation should support the number of units billed.

 

 

Thanks

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