Primary Care Coding Alert

Question: We recently submitted a claim of 99214-25, 64400 x2, and 64505 x2, which was denied by Medicare using reason code 151. What did we do wrong, and what modifiers should we use to resubmit this claim?

Codify Subscriber

Answer: The reason for the denial on this claim can be fixed by modifying the services. Here’s why and how.

First, providing your documentation can support a significant, separate evaluation and management (E/M) visit for the encounter, your use of modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) with 99214 (Office or other outpatient visit for the evaluation and management of an established patient …) is correct, so there is no need to change this part of the claim.

Next, there are no National Correct Coding Initiative (NCCI) edits preventing you from billing 64400 (Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)) together with 64505 (Injection, anesthetic agent; sphenopalatine ganglion), either as a Column 1 or a Column 2 code. So, a modifier such as 59 (Distinct Procedural Service) is not necessary to unbundle the services.

But a close look at Medicare reason code 151 tells you what kind of modifier you will need. The code states that Medicare has adjusted your payment “because the payer deems the information submitted does not support this many/frequency of services.” This should refer you to the codes’ Medicare Medically Unlikely Edit (MUE) units and MUE Adjudication Indicator (MAI), which are as follows:

For 64400: MUE - 4 units; MAI - 3.

For 64505: MUE - 1 unit; MAI - 3.

The MUE for the codes mean that Medicare will pay for a total of four units of 64400, but just one unit of 64505, on the same date of service. So, your claim for two units of 64400 is allowable under Medicare rules, but your claim for two units of 64505 is above the single unit allowance for the code; hence, the denial.

However, per the NCCI Policy Manual, Medicare contractors may bypass MUEs with an MAI of 3 during claims processing if they “have evidence (e.g. medical review) that UOS [units of service] in excess of the MUE value were actually provided, were correctly coded, and were medically necessary” (Source: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd).

In your particular example, you don’t mention why your provider administered two units of 64505. But if you can document that both units were medically necessary (e.g. your provider administered the sphenopalatine ganglion block to both of the patient’s nostrils), then appending the appropriate modifier (e.g. modifier 50 [Bilateral Procedure]) to the 64505 should signal to the Medicare administrative contractor that there is a reason to override the MUE units and ensure payment of $195.96 for 64505-50 based on 150 percent of the procedure’s single-unit fee of $130.64. Even if 64505-50 still generates a denial, you may be able to appeal with documentation establishing the medical necessity of two units of service and get paid.