MUE for CPT Code 11045

kay.larsen@ah.orgkay.larsen@ah.org
edited January 28 in DENIALS & APPEALS

Is there any way around the MUE limit for CPT Code 11045? What is the best way to get as much as we can? Do we bill for the covered and place the excess quantity in the non-covered column or do we appeal? If appeal is our only option, are there any magic words to use to convince Mcare to pay us?

Total wound size is 288 sq cm. 2 units over the MUE for 11045.

Is there any point in appealing since 11045 has a SI of N?

Thanks!

Comments

  • slgincconsulting@aol.comslgincconsulting@aol.com

    Hi, Kay. Please check out this page on CMS: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-faq-library and this MLN Matters article: https://www.cms.gov/files/document/revised-modification-medically-unlikely-edit-mue-program-mm8853.pdf. CPT 11045 has an MAI of 3, which means it is appealable with the appropriate documentation.  

    "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."

    "If, during reopening or redetermination, medical records are provided with respect to an MUE denial for an edit with an MUE Adjudication Indicator (MAI) of “3,” MACs will review the records to determine if the provider/supplier actually furnished units in excess of the MUE, if the codes were used correctly, and whether the services were medically reasonable and necessary. If the units were actually provided but one of the other conditions is not met, a change in denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding to a determination that the item/service is not reasonable and necessary under section 1862(a)(1))." 

    Hope this helps!

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