Medically Unlikely Edits Deviations

Policy ID: NDRP-GC-017

Section: General Coding

Effective Date: July 01, 2018

Revised Date: March 01, 2023

Last Reviewed: January 13, 2023

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 beneficiary.

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

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

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

99202

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

8/1/2020

99203

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.

8/1/2020

99204

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.

8/1/2020

99205

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.

8/1/2020

99211

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.

8/1/2020

99215

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

8/1/2020

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

J0690

Injection, Cefazolin Sodium, 500 mg

7/1/2018

J0696

Injection, Ceftriaxone Sodium, per 250 mg

7/1/2018

J0744

Injection, Ciprofloxacin for intravenous infusion, 200 mg

7/1/2018

J0878

Injection, Daptomycin, 1 mg

1,608

2/1/2023

J1572

Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, non-lyophilized (e.g., liquid), 500 mg

300

2/1/2023

J2543

Injection, Piperacillin Sodium/Tazobactam Sodium, 1 gram/0.125 grams (1.125 grams)

7/1/2018

J3475

Injection, Magnesium Sulfate, per 500 mg

2/1/2023

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, 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

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.

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