Oncology & Hematology Coding Alert

Question: Why did we get a denial from Medicare for 4 units of +96367?

New Mexico Subscriber

Answer: The culprit is probably a Medically Unlikely Edit (MUE) of 3 for +96367 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion of a new drug / substance, up to 1 hour [List separately in addition to code for primary procedure]).

CMS states that MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have, so you shouldn't need to override them often. But you can override an MUE when your physician performs and documents a medically necessary number of services that exceed the limit.

To override the MUE (when you are absolutely positive your documentation of orders, times, medical necessity, and everything else will support all the units you want to report), you may submit +96367 x 3 on one line and then +96367-59 (Distinct procedural service) with up to three additional units on a separate line. (Theoretically, you could do additional lines with up to three units each as needed.)

CMS notes that modifiers 76 (Repeat procedure by same physician or other qualified health care professional) and 77 (Repeat procedure by another physician or other qualified health care professional) are among your options to override an MUE, as are the anatomical modifiers, such as RT (Right side). But in this case, modifier 59 is the best fit. (Search for answer ID "8736" at https://questions.cms.hhs.gov/app/home to see a CMS FAQ on the topic.)

Expect to supply documentation showing medical necessity for the additional units. And if you receive a claim denial due to MUEs, you can appeal.

CMS doesn't publish all MUEs, but you can find those they do by downloading the Practitioner Services MUE table from www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp. The list referenced here was updated Jan. 1, 2012.