Wiki MUEs for 28300

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kelly.armstrong

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I've seen several references that the MUEs for 28300 were changed from one to two. However, I am still getting denials for the second 28300-59. Is anyone having any luck getting the second one paid?

Thanks!

Kelly
 
You have to appeal the additional unit. It changed to MAI 3. It's not just going to be automatically paid.
MUEs for HCPCS codes with a MAI of “3”
MUEs for HCPCS codes with a MAI of “3” are date of service edits. These are “per day edits based on clinical benchmarks”. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal.
 
amyjph said:
It's the adjudication indicator. The MUE is still 1, but the MAI went from 2 to 3.
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Yep. It looks like AAOS asked for the MUE to be updated, but instead the adjudication indicator was updated from 2 to 3. (Which I guess at least gives the ability to appeal, even though it wasn't the unit update that AAOS asked for.)

BTW - when I did a quick google search, I did find this press release where AAOS had requested the unit update. If you've stumbled across this, I can see where it would be confusing and seem like CMS was going to update the MUE units:

 
sls314 said:
Yep. It looks like AAOS asked for the MUE to be updated, but instead the adjudication indicator was updated from 2 to 3. (Which I guess at least gives the ability to appeal, even though it wasn't the unit update that AAOS asked for.)

BTW - when I did a quick google search, I did find this press release where AAOS had requested the unit update. If you've stumbled across this, I can see where it would be confusing and seem like CMS was going to update the MUE units:

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Yes, that AAOS press release was the one I was referring to. :) I did see the MAI went from 2 to 3.

Thanks for your help!
 
amyjph said:
You have to appeal the additional unit. It changed to MAI 3. It's not just going to be automatically paid.
MUEs for HCPCS codes with a MAI of “3”
MUEs for HCPCS codes with a MAI of “3” are date of service edits. These are “per day edits based on clinical benchmarks”. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal.
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I did appeal it and they still denied it (BCBS) I am going to Appeal again and use some of the verbiage you used, if you don't mind. :)
 
Also, did you bill it on two lines with one unit per line or one line with two units? I assume two separate lines with one unit since you said you appended a 59.

If that doesn't work another option *might* be apending a 22 to the one unit of 28300 if the documentation supports osteotomy being done at two separate spots on the calcaneus to correct.
 
amyjph said:
Also, did you bill it on two lines with one unit per line or one line with two units? I assume two separate lines with one unit since you said you appended a 59.

If that doesn't work another option *might* be apending a 22 to the one unit of 28300 if the documentation supports osteotomy being done at two separate spots on the calcaneus to correct.
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I did two separate lines with one unit per line and a 59 on the second one. I will try adding mod 22 (and deleting the 2nd line) if it gets denied again. I did see that mentioned somewhere in my reading. Thanks for your help!
 
Kelly, the MUE remains at only one. The references are incorrect or perhaps the recommendation was never enacted. It CAN be billed bilateral, however, on one line with 50 modifier, 1 unit and double the price. If there were 2 osteotomy surgical fractures performed on the same calcaneus in different areas of the calcaneus, that is billed just one time with one code. No amount of rebilling with modifier 59, nor any of the other recommended scenarios will get 2 units paid on the same DOS. Modifier 22 is not appropriate, either, in my opinion.
 
podcoder70 said:
Kelly, the MUE remains at only one. The references are incorrect or perhaps the recommendation was never enacted. It CAN be billed bilateral, however, on one line with 50 modifier, 1 unit and double the price. If there were 2 osteotomy surgical fractures performed on the same calcaneus in different areas of the calcaneus, that is billed just one time with one code. No amount of rebilling with modifier 59, nor any of the other recommended scenarios will get 2 units paid on the same DOS. Modifier 22 is not appropriate, either, in my opinion.
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Thanks for the info. I used to only bill it one time until we had our billing and coding update training in December hosted by Decision Health. They are the ones who said it is now billable twice. But since I'm seeing a denial every time I bill it twice, I am in agreement with you. Thanks for you insight!
 
Good feedback Tonia. I haven't seen anything about the next quarter MUE updates. Doubtful it will be updated to 2 at the next release.

I agree the MUE is only one, but the MAI was changed and according to CMS: "MUEs for HCPCS codes with a MAI of “3” are date of service edits. These are “per day edits based on clinical benchmarks”. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal."

I'm not saying it will work, but it is "possible" according to that. The documentation would have to be bullet-proof and that's a lot of "if's" above. I would be interested to know if anyone has ever successfully done this. I never have. It's the if, when, but, except, and, of coding lol

I also agree it's highly doubtful to impossible it will pay for more than 1 unit, unless bilateral. I don't think I have ever seen bilateral 28300 because the patient probably wouldn't be able to ambulate after. Has anyone ever seen a bilateral 28300?

Agree that bilateral would be billed one unit, one line, 50 mod however, there are some (random) payers that accept/require two lines RT/LT. The 50 mod one unit way is best generally though. Example: https://www.brainshark.com/1/player/humana?fb=0&r3f1=&custom=bilateralv3
Example: TX Medicaid https://www.tmhp.com/sites/default/...3/2023-04-april/2_Med_Specs_and_Phys_Srvs.pdf "9.2.71.4 Bilateral Procedures When a bilateral procedure is performed and an appropriate bilateral code is not available, a unilateral code must be used. The unilateral code must be billed twice with a quantity of 1 for each code. For all procedures, use modifiers LT (left) and RT (right) as appropriate."

A 22 may not be applicable in the case discussed here but there are times when it might be. Again, the documentation would have to support it and be explicitly clear to justify significantly greater effort, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical/mental effort required, than usual.

Additionally, unless your practice and providers are high volume for this and big reconstruction/deformity cases, is it worth all the extra time and effort to try only to be denied anyway? I would probably run a CPT report to see how many times 28300 was billed in a recent timeframe. It may not be worth pursuing aggresively if resources are limited and coding/AR time is better spent somewhere else. I know providers want us to fight for every penny but sometimes that's just not gonna happen with people resources vs. volume.

I would love to read the article in the April 22 issue of AAOS now but can't access. Anyone have it? https://www.aaos.org/aaosnow/2022/apr/managing/managing01/
 
amyjph said:
Good feedback Tonia. I haven't seen anything about the next quarter MUE updates. Doubtful it will be updated to 2 at the next release.

I agree the MUE is only one, but the MAI was changed and according to CMS: "MUEs for HCPCS codes with a MAI of “3” are date of service edits. These are “per day edits based on clinical benchmarks”. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal."

I'm not saying it will work, but it is "possible" according to that. The documentation would have to be bullet-proof and that's a lot of "if's" above. I would be interested to know if anyone has ever successfully done this. I never have. It's the if, when, but, except, and, of coding lol

I also agree it's highly doubtful to impossible it will pay for more than 1 unit, unless bilateral. I don't think I have ever seen bilateral 28300 because the patient probably wouldn't be able to ambulate after. Has anyone ever seen a bilateral 28300?

Agree that bilateral would be billed one unit, one line, 50 mod however, there are some (random) payers that accept/require two lines RT/LT. The 50 mod one unit way is best generally though. Example: https://www.brainshark.com/1/player/humana?fb=0&r3f1=&custom=bilateralv3
Example: TX Medicaid https://www.tmhp.com/sites/default/...3/2023-04-april/2_Med_Specs_and_Phys_Srvs.pdf "9.2.71.4 Bilateral Procedures When a bilateral procedure is performed and an appropriate bilateral code is not available, a unilateral code must be used. The unilateral code must be billed twice with a quantity of 1 for each code. For all procedures, use modifiers LT (left) and RT (right) as appropriate."

A 22 may not be applicable in the case discussed here but there are times when it might be. Again, the documentation would have to support it and be explicitly clear to justify significantly greater effort, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical/mental effort required, than usual.

Additionally, unless your practice and providers are high volume for this and big reconstruction/deformity cases, is it worth all the extra time and effort to try only to be denied anyway? I would probably run a CPT report to see how many times 28300 was billed in a recent timeframe. It may not be worth pursuing aggresively if resources are limited and coding/AR time is better spent somewhere else. I know providers want us to fight for every penny but sometimes that's just not gonna happen with people resources vs. volume.

I would love to read the article in the April 22 issue of AAOS now but can't access. Anyone have it? https://www.aaos.org/aaosnow/2022/apr/managing/managing01/
Click to expand...
I wasn't able to open the article either. I did go ahead and send a 2nd appeal yesterday with some info regarding the MAI of 3 etc. I code for a surgeon who does only feet/ankles and he does 28300 a lot. When we had our coding updates training in December my boss even made a point of saying how this doctor would be so happy that I can now code it twice.

Decision Health, during training, specifically said "For 28300 - Calcaneal Ostoetomy - MUE's now allow TWO. Does your surgeon do lateral column lenthening calcaneus and also medial medalizing calcneus? If so, Two separate conditions, TWO separate incisions. Appeal the denials". Then there is info listed to include in an appeal.

I wonder why they would say this if the change from one MUE to two MUE's was never approved by CMS. I've spent a lot of time trying to get the 2nd 28300 paid on about 4 claims so far. So yes, we do quite a few of these and I don't want to continue spending time appealing if they are not going to pay. Of those 4, we've had to appeal and are waiting to see if deny again.

I'm having similar issues coding 28270 with 28285. Same doctor as above does a lot of these. In our December training, Decision Health said 28270 is payable as long as OP report shows 2 different deformities, which it does. So I've been coding 28285 and 28270-59 and the 28270-59 keeps getting denied. That should be another thread though. :)
 
I always take consultant, external advice and training or seminars with a grain of salt. Trust, but verify type of thing. Just like these forums :) That's why there's always little disclaimers on those. The payer you are billing may not give two hoots either if their policy says no.

Your consultant information was not accurate or they thought it was accurate at the time the presentation was made. I would ask for clarification and/or reputable citations. Dare I say they rwere going by the AAOS article but never followed up or just assumed it was 2?

Yes, the old capsulotomy and hammertoe debate. The problem with that is the "separate procedure" designation of the 28270. It's inclusive to the more complex service. I know AAOS GSD says it's not included in the 28285 when the MTP has a contracture. I have run into the same issues trying to report those 2 as well. Have you appealled any? Does the op report and dx support contracture for the 28272? I don't know that it would matter due to the separate procedure designation. It's kind of pointless to try and do it, to those that follow CMS/NCCI anyway.
https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-4.pdf
I. General Policy Statements
"26. If the code descriptor of a HCPCS/CPT code includes the phrase “separate procedure,” the procedure is subject to NCCI PTP edits based on this designation. CMS does not allow separate reporting of a procedure designated as a “separate procedure” when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach."
J. CPT “Separate Procedure” Definition
"If a CPT code descriptor includes the term “separate procedure,” the CPT code may not be reported separately with a related procedure."
 
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