Wiki Please Help 77300 MUE

[RaeToll]

I am a UR nurse asked to review a claim denial for medical necessity where CPT 77300 denied as exceeding MUE. MUE is 10 units. What was billed on the UB04 is 77300 x 10 units and 77300-59 x 73 units.
Are the units for 77300 referred to as "shots"? I would like to confirm I'm reading the treatment summary correctly. I truly truly appreciate any guidance anyone can provide.

 

[sls314]

I am a UR nurse asked to review a claim denial for medical necessity where CPT 77300 denied as exceeding MUE. MUE is 10 units. What was billed on the UB04 is 77300 x 10 units and 77300-59 x 73 units.
Are the units for 77300 referred to as "shots"? I would like to confirm I'm reading the treatment summary correctly. I truly truly appreciate any guidance anyone can provide.

I currently code the physician side of Radiation Therapy, and I also used to work in facility reimbursement contracting. So, I can offer a little information and also a little insight.

77300 is a dosimetry calculation. You might also see it documented as a "dose calc." It's the mathematical calculation to determine the radiation dose distribution. In the context of Gamma Knife, it can also be called a shot.

77371 is the facility's charge for the complete course of treatment of Stereotactic Radiosurgery (SRS) in one session. (Gamma Knife is a form of Sterotactic Radiosurgery with a Cobalt-60 machine.)

If this is a Medicare patient, I can tell you that CMS will reimburse a Comprehensive APC (C-APC) payment for 77371. Your 77300 and 77344 don't get reimbursed separately - it is bundled into the C-APC payment for 77371.

If this is a Commercial insurance patient, most facility insurance contracts will typically have a fixed case rate for Gamma Knife services. You should be able to verify that for the specific patient's insurance.

For you as a UR nurse, I can tell you that this claim is probably not worth you spending a lot of time on.

1) It's unlikely that you'd ever get approved to exceed the MUE of 10 for 77300 regardless of what you sent in.

2) Even if you did by some chance get the MUE overturned, it likely wouldn't affect total reimbursement the facility would receive anyhow.

The facility's reimbursement is going to be driven by the 77371 as that case rate or comprehensive APC. Because of that, it likely wouldn't matter if there were 3, 10, or 83 units of 77300 on the claim - it all gets bundled into the comprehensive payment the facility receives for 77371 anyhow.

IMO, I'd issue a corrected claim for the 10 MUE units, so the insurance can pay the 77371. That way it frees your time for denial reviews that actually could bring in additional reimbursement for the facility!

Good luck!

BTW - ASTRO is a great resource if you ever need to look at future radiation therapy claims: https://www.astro.org/Daily-Practice/Coding

 

[RaeToll]

I currently code the physician side of Radiation Therapy, and I also used to work in facility reimbursement contracting. So, I can offer a little information and also a little insight.

77300 is a dosimetry calculation. You might also see it documented as a "dose calc." It's the mathematical calculation to determine the radiation dose distribution. In the context of Gamma Knife, it can also be called a shot.

77371 is the facility's charge for the complete course of treatment of Stereotactic Radiosurgery (SRS) in one session. (Gamma Knife is a form of Sterotactic Radiosurgery with a Cobalt-60 machine.)

If this is a Medicare patient, I can tell you that CMS will reimburse a Comprehensive APC (C-APC) payment for 77371. Your 77300 and 77344 don't get reimbursed separately - it is bundled into the C-APC payment for 77371.

If this is a Commercial insurance patient, most facility insurance contracts will typically have a fixed case rate for Gamma Knife services. You should be able to verify that for the specific patient's insurance.

For you as a UR nurse, I can tell you that this claim is probably not worth you spending a lot of time on.

1) It's unlikely that you'd ever get approved to exceed the MUE of 10 for 77300 regardless of what you sent in.

2) Even if you did by some chance get the MUE overturned, it likely wouldn't affect total reimbursement the facility would receive anyhow.

The facility's reimbursement is going to be driven by the 77371 as that case rate or comprehensive APC. Because of that, it likely wouldn't matter if there were 3, 10, or 83 units of 77300 on the claim - it all gets bundled into the comprehensive payment the facility receives for 77371 anyhow.

IMO, I'd issue a corrected claim for the 10 MUE units, so the insurance can pay the 77371. That way it frees your time for denial reviews that actually could bring in additional reimbursement for the facility!

Good luck!

BTW - ASTRO is a great resource if you ever need to look at future radiation therapy claims: https://www.astro.org/Daily-Practice/Coding

This makes sense. Thank you for taking the time to explain this.

 

[lal4381@yahoo.com]

I came upon this post while searching for anyone with a similar case that I was working on with a colleague.
I found this information in a book by Revenue Cycle Coding Strategies for Radiation Oncology.
External beam radiosurgery using a linear accelerator includes a number of ports, or beam entry points that channel radiation into the patient, Cobalt-60 treatment with a Leksell Gamma Knife works in a slightly different way. A single patient treatment may require the use of more than one collimator to ensure the best possible radiation distribution. When a collimator is changed, or when certain holes in the collimator are opened or closed, the patient is typically removed from the treatment chamber. The process of adjusting or changing collimators is repeated until as much of the target volume as possible has been treated. Each time the patient is returned to the chamber for radiation delivery it is referred to as a "shot" of radiation treatment.
While each shot of radiation targets the tumor volume, the radiation delivery does not overlap. Instead, each small shot targets an area of tumor volume until the entire neoplasm has been treated with the optimal dose of radiation. For Cobalt-60 radiosurgery, each shot is considered to be a unit of basic calculation (procedure code 77300), subject to bundling guidelines). For example, if three shots are required in a Leksell Gamma Knife treatment plan, procedure code 77300 would be reported with three units. Some payers may impose a "cap" on the total number of calculations reimbursed, and Medicare has implemented an MUE allowance of 10 units.