Revenue Cycle

Scenario: Appealing denied units when a service exceeds MUE limits

Medicare Update for CAHs, September 7, 2011

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Consider this example: On February 1, 2011, a hospital performed a lab test that is paid under the laboratory fee schedule, and per the physician’s order, the hospital performed the medically necessary test five times on the same date of service. The line item for the lab was denied stating they had exceeded the maximum number of units for that HCPCS code. After looking a bit further, the hospital determined that all five tests were medically necessary and they identified in the medically unlikely edit table that the maximum number of units for that HCPCS code was three. Based on CMS guidance, can the hospital appeal the denial?

Yes – effective April 1, 2010, the hospital can appeal denied units when a service exceeds the MUE unit limits. However, to avoid a denial, the hospital could bill the test on two separate lines since each line on a claim is adjudicated separately (i.e. three units of the HCPCS code on one line with modifier 91 and two units on another line with the same HCPCS code, also with modifier 91). Transmittal 652 and 949> >

 This scenario/tip was adapted from HCPro’s Medicare Boot Camp® - Critical Access Hospital Version.



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