Wiki CPT Edit

[amylis1]

Hi Everyone,

Please explain to me what this edit means:
HCPCS total units exceed daily allowed Medically unlikely Edit maxium of 1 based on clinical benchmarks.

This is an U/S of RT side upper and lower extremites, no AAPC'c calculating.
I believe 93971 can only be billed once?

Correct?

 

[shellysk8]

MUE Edit

Hi,

You are correct, only 1 unit of CPT 93971 can be billed. Per the description of the code, it is for a unilateral study. If the service is done bilaterally, you would bill 93970. If you read the description of 93970, it indicates "complete" bilateral, which would include all 4 extremities, so the unilateral would include arm and leg on one side.

In some cases, you can bill above the MUE value by splitting lines - the MUE value on 1 line, and the additional units on another, and then send in documentation on why the additional units were medically necessary. That works in cases of injections and such. That wouldn't work in this case since the MUE value is set based on the CPT code description rather than a value being set on the "likely" number of a procedure a patient would receive on a given date.

I hope this helps!
Shelly Kubacki, MPA, CPC

 

[thomas7331]

The MUE edit of 1 is for 'unlikely', so these are set to automatically deny, but you should be able to appeal with records in this situation and get payment. I imagine they are setting it up this way to avoid paying twice for a bilateral procedure when there is another more appropriate code available, but that's not the case in your situation where you have two unilateral procedures.

 

[thomas7331]

Just add, the AMA CPT Assistant states "It is appropriate to report CPT code 93970, Duplex scan of extremity veins ...once for the upper extremity veins and once for the lower extremity veins when bilateral study of both upper and lower extremities are performed. This code is intended to identify either the upper or the lower extremities, and modifier 59 may be appended to denote that separate and distinct procedures were performed. " 93970 is also set up with MUE of 1, so I would imagine the same thing would apply for 93971.