Ophthalmology and Optometry Coding Alert

Question: I keep receiving denials for frequency when submitting two units of 65091 with modifiers LT and RT to Medicare. Why might this be happening?

Georgia Subscriber

Answer: The likely culprit for the denial is the code’s medically unlikely edit (MUE). MUEs indicate a unit of service (UOS) edit for services rendered by a single provider to a single patient on the same date of service. The units on each line on the claim are totaled. The ideal MUE is the maximum units that may be reported for a CPT^® code.

CPT^® 65091 (Evisceration of ocular contents; without implant) has an MUE of 1, which means that only one unit may be submitted on a given date of service. Consequently, a submission of 65091 on separate lines with modifiers LT (Left side) and RT (Right side), each with one unit, will exceed the maximum MUE for that code and results in a flag in the Medicare system, leading to a denial. To circumvent this, submit the claim as one unit with modifier 50 (Bilateral procedure) instead.