Medically Unlikely Edits Deviations

Policy ID: NDRP-GC-017

Section: General Coding

Effective Date: July 01, 2018

Revision Effective Date: March 14, 2025

Last Reviewed: February 11, 2025

Applies To: Commercial Only

Description

This policy outlines Blue Cross Blue Shield of North Dakota (BCBSND) Medically Unlikely Edit (MUE) deviations from the Centers for Medicare & Medicaid (CMS) MUE values.

Description

Medically Unlikely Edit

An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single member.

MUEs are developed based on HCPCS/CPT code descriptors, coding instructions, anatomic considerations, established CMS policies, nature of service/procedure, nature of analyte, nature of equipment, prescribing information, and clinical judgment.

Note: Not all HCPCS/CPT codes have an MUE.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Policy

BCBSND identified the codes below to deviate from the CMS MUE values. This applies to codes submitted on the CMS-1500 Claim Form.

Code

Description

BCBSND MUE Value

Effective Date

95165

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)

None

4/1/2024

96137

Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes

None

2/1/2023

96139

Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes

None

2/1/2023

A0425

Ground Mileage, per statute mile

None

7/1/2018

A0435

Fixed wing air mileage, per statute mile

None

7/1/2018

A0436

Rotary wing air mileage, per statute mile

None

7/1/2018

J1628

Injection, guselkumab, 1 mg

200 units

10/1/2024

Limitations & Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross References

History

Date

Updates

9/22/2020

Terminating the MUE deviation for 99201-99215 as of 09/30/2020 due to realigning with CMS. Added new deviation for 96171.

7/16/2020

Addendum was updated to include MUE deviations for 99201-99215 and 90832, 90834 and 90837.

9/30/2020

Terminated MUE deviation for codes 99201-99215 now following CMS MUE values effective 10/1/2020.

9/9/2021

Updated to new format and added CMS NCCI cross reference

4/1/2022

Added J2426 MUE deviation effective 4/1/2022.

8/1/2022

Policy reviewed and removed 99201 from list as this is a deleted code

9/23/2022

Removed J1559 from list as BCBSND will be following CMS’ MUE value as of 10/1/2022.

2/1/2023

Revised BCBSND MUE Values for codes 96137, 96139, J0878, J3475, V2520, V2521, V2522 and V2523. Added J1572 to list effective 2/1/2023. Removed 90832, 90834, 90837, 96171, 99212, 99213, 99214, J0202, J0295, J0461, J0743, J1000, J1040, J1580, J1726, J2426, J2675, J2790, J3370, J3590, J7178, J7179, J7180, J7181, J7183, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7198, J7200, J7201, J7202, J7205, J7207, J7209, J9060, J9260 and Q9966 from list as BCBSND will be following CMS’ MUE values as of 2/1/2023.

2/3/2023

Removed V2520, V2521, V2522, and V2523 from list as BCBSND will be following CMS’ MUE values.

3/1/2023

Removed 95165 from list as BCBSND will be following CMS’ MUE value effective 3/1/2023

3/24/2023

Deleted codes 99201-99215 as BCBSND has been following CMS MUE values since 10/1/2020.

6/29/2023

Deleted code J0969, J0744, J0878, J1572 and J2543 as BCBSND will be following CMS’ MUE value effective 9/1/2023.

1/15/2024

Added 95165 back to the list of codes effective 4/1/2024.

2/13/2024

Annual review completed. Added legal disclaimer “All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.”, added “payment integrity edits” to the Limitations and Exclusions section and changed “Revised Date:” to “Revision Effective Date:”.

2/11/2025

Annual review completed.

3/3/2025

Added J1628 with deviated MUE value of 200 units, effective 10/1/2024.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.

Policy ID: NDRP-GC-017

Section: General Coding

Effective Date: July 01, 2018

Revision Effective Date: April 08, 2024

Last Reviewed: February 11, 2025

Archived Date: March 13, 2025

Applies To: Commercial Only

Description

This policy outlines Blue Cross Blue Shield of North Dakota (BCBSND) Medically Unlikely Edit (MUE) deviations from the Centers for Medicare & Medicaid (CMS) MUE values.

Description

Medically Unlikely Edit

Note: Not all HCPCS/CPT codes have an MUE.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Policy

BCBSND identified the codes below to deviate from the CMS MUE values. This applies to codes submitted on the CMS-1500 Claim Form.

Code

Description

BCBSND MUE Value

Effective Date

95165

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)

None

4/1/2024

96137

Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 30 minutes

None

2/1/2023

96139

Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes

None

2/1/2023

A0425

Ground Mileage, per statute mile

None

7/1/2018

A0435

Fixed wing air mileage, per statute mile

None

7/1/2018

A0436

Rotary wing air mileage, per statute mile

None

7/1/2018

Limitations & Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross References

History

Date

Updates

9/22/2020

Terminating the MUE deviation for 99201-99215 as of 09/30/2020 due to realigning with CMS. Added new deviation for 96171.

7/16/2020

Addendum was updated to include MUE deviations for 99201-99215 and 90832, 90834 and 90837.

9/30/2020

Terminated MUE deviation for codes 99201-99215 now following CMS MUE values effective 10/1/2020.

9/9/2021

Updated to new format and added CMS NCCI cross reference

4/1/2022

Added J2426 MUE deviation effective 4/1/2022.

8/1/2022

Policy reviewed and removed 99201 from list as this is a deleted code

9/23/2022

Removed J1559 from list as BCBSND will be following CMS’ MUE value as of 10/1/2022.

2/1/2023

2/3/2023

Removed V2520, V2521, V2522, and V2523 from list as BCBSND will be following CMS’ MUE values.

3/1/2023

Removed 95165 from list as BCBSND will be following CMS’ MUE value effective 3/1/2023

3/24/2023

Deleted codes 99201-99215 as BCBSND has been following CMS MUE values since 10/1/2020.

6/29/2023

Deleted code J0969, J0744, J0878, J1572 and J2543 as BCBSND will be following CMS’ MUE value effective 9/1/2023.

1/15/2024

Added 95165 back to the list of codes effective 4/1/2024.

2/13/2024

2/11/2025

Annual review completed.

Disclaimer

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Medically Unlikely Edits Deviations

Description

Policy Application

Policy

Limitations & Exclusions

Cross References

History

Disclaimer

Description

Policy Application

Policy

Limitations & Exclusions

Cross References

History

Disclaimer