General Surgery Coding Alert

The Centers for Medicare & Medicaid Services (CMS) states that MUEs reflect the maximum number of units most of the properly reported claims for a particular code would have. This has been carefully calculated; therefore, you shouldn’t need to override them very often. As you suspect, when the physician performs and documents a medically necessary number of services that exceeds this limit, you can sometimes override the MUE.

To figure out which circumstances might call for this, take a close look at the MUE table and see that it includes a column for “MUE Adjudication Indicator” (MAI). This provides guidance about what circumstances allow you to override an MUE limit for a given code. If the code has an MAI of “1,” the code is adjudicated on a claim-line basis, meaning that you can’t exceed the number of MUE units on a claim line. You are allowed to use one of the distinct-service modifiers (such as modifier 59 or the “X” modifiers) to override the edit if circumstances warrant.

An MAI of “2” means that the frequency limit is absolute for a date of service — you cannot override the edit with a modifier.

An MAI of “3” means that the frequency limit is based on the date of service, and Medicare will automatically deny any claims in excess of that limit, even if you use an appropriate modifier. However, Medicare will consider an appeal with appropriate documentation.

In the case of 43605, the MAI is 2, meaning that you can report just one once per date of service and cannot override the edit.

Basis: Because the code describes the entire open procedure for the anatomic site “stomach,” not just the biopsy snip for a specific location on the stomach, CMS essentially restricts you to reporting one unit of code 43605 even if the surgeon takes multiple biopsy samples.