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Medically Unlikely Edits Problem

We have become aware of claim denials beginning with dates of service on April 1, 2013, or later for unilateral procedures done on both eyes on the same date of service based on medically unlikely edits (MUE). We understand from several clients that claims such as bilateral upper lid blepharoplasty, 15823-RT combined with 15823-LT, are being denied; likewise for ptosis repair and other procedures. The remittance advice (RA) may show denial reason code CO-151 and remittance advice code N362, which deal with “units”. Those codes are as follows:

CO151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Start: 10/31/2002 | Last Modified: 01/27/2008
N362 The number of Days or Units of Service exceeds our acceptable maximum.
Start: 11/18/2005

 

We have been asked whether using a single line on the claim with modifier -50 will help. We believe it will. Payers have received instructions from NCCI that this should be the correct methodology; it also agrees with CPT instructions for the use of modifier -50. Using the example above, billing 15823-50 with units of “1” is correct according to the Medicare instructions related to MUE, but we have received reports that some early claims configured in this way were denied with the same CO151 and N362 codes. Apparently, there may be a new problem with computer processing of claims subject to MUE. While it may be fixed by the time of your claims filing, be aware that MACs may not have the “fix” in place as of this date.

In our view, the promulgation of the MUE for bilateral procedures has been ill-conceived, inappropriate, and could lead to unintended consequences such as serial surgery on different days – which we do not advise. We strongly encourage you to contact your MAC and verify that they want claim information as below. As always, be sure that a covered diagnosis is included on your claim.

 

CPT CODE Modifier Units Fee
Bleph, Ptosis as appropriate(Ex: 15823) 50 1 Double the usual one eye fee, payment subject to multiple procedure rules

 

Finally, we feel it is in your interest to notify your state or local medical societies of these MUE and payment issues.

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