Oncology & Hematology Coding Alert

Question: Can we charge 77295 for two different body parts if the plan is signed on the same DOS?

AAPC Forum Participant

Answer: The medically unlikely edits (MUEs) for 77295 (3-dimensional radiotherapy plan, including dose-volume histograms) is one unit per date of service (DOS).

However, 77295 has an MUE adjudication indicator (MAI) of 3. This means Medicare will allow you to appeal the denial of units of service (UOS) over the MUE for the DOS based on medical necessity. For more information, you can consult the Centers for Medicare & Medicaid Services (CMS) Manual 100-20 Transmittal 1421. This tells you “contractors may pay UOS in excess of the MUE value if there is pre-payment adequate documentation of medical necessity or on appeal of the denied claim(s).”

Remember: CMS established MUEs as a unit-of-service edit for HCPCS Level II and CPT^® codes. An MUE is assigned to a

specific code to represent the maximum number of units of the code that you should report — either on a specific claim or on a specific date.

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 to override the edit if circumstances allow, such as 59 (Distinct procedural service) or the following X{EPSU} modifiers:

• XE (Separate encounter …)
• XP (Separate practitioner …)
• XS (Separate structure …)
• XU (Unusual non-overlapping service …)

An MAI of “2” means that the frequency limit is absolute for a date of service, and you may not 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.

It is also important to ask yourself if more than one procedure could be warranted as an exception. For example:

• Are there two separate radiation therapies on the two separate sites?
• Are there two separate dosimetry calculations?

Keep in mind that there must be two completely separate sets of calculations, plans, and therapies to bill for this twice, exceeding the MUE as an exception, which is rare.