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Q/A: Billing for CPT Code 86022

APCs Weekly Monitor, May 1, 2009

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Q. We sent blood to the Red Cross, where it was screened against eight apheresis donors. The Red Cross charged us for each screening but when we try to bill Medicare (CPT code 86022) they say we cannot bill for more than one.

Our billing department told me the reimbursement for this service does not cover the charge for even one unit charged by the Red Cross, let alone eight. Have you heard of this issue? Do you have any suggestions?      

A. There is some contradictory guidance in this area.

The Medicare Program Integrity Manual, Transmittal 178, from December 8, 2006, states that if a line item (or all line items for the same HCPCS code on the same date of service) exceeds the Medically Unlikely Edit (MUE) unit limit (which in this case is one) the claim will be returned to provider (RTP).

The same transmittal also states that providers cannot appeal claims that are RTP due to an MUE edit. However, FAQ 8736 asks the question “How do I report medically reasonable and necessary units of service in excess of a MUE value?” The FAQ answer is:

Since each line of a claim is adjudicated separately against the MUE value for the code on that line, the appropriate use of Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable providers/suppliers to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as -76 (repeat procedure by same physician, -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test) and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service.

Some facilities have had success reporting such values on separate lines, but it is unclear. how they would fare in an audit.

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