Medically Unlikely Edits Deviations

Policy ID: NDRP-GC-017

Section: General Coding

Effective Date: July 01, 2018

Revised Date: September 09, 2021

Last Reviewed: September 09, 2021

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
90832	Psychotherapy, 30 minutes with patient	1	8/1/2020
90834	Psychotherapy, 45 minutes with patient	1	8/1/2020
90837	Psychotherapy, 60 minutes with patient	1	8/1/2020
95165	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single or multiple antigens	None	4/1/2019
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	17	1/1/2019
96139	Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes	17	1/1/2019
96171	Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service)	None	10/1/2020
99201	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making.	2	8/1/2020
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.	2	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.	2	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.	2	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.	2	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.	2	8/1/2020
99212	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.	2	8/1/2020
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.	2	8/1/2020
99214	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.	2	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.	2	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
J0202	Injection, Alemtuzumab, 1 mg	41	7/1/2018
J0295	Injection, Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm	18	7/1/2018
J0461	Injection, Atropine Sulfate, 0.01 mg	100,000	7/1/2018
J0690	Injection, Cefazolin Sodium, 500 mg	24	7/1/2018
J0696	Injection, Ceftriaxone Sodium, per 250 mg	42	7/1/2018
J0743	Injection, Cilastatin sodium, Imipenem, per 250 mg	54	7/1/2018
J0744	Injection, Ciprofloxacin for intravenous infusion, 200 mg	20	7/1/2018
J0878	Injection, Daptomycin, 1 mg	2,000	7/1/2018
J1000	Injection, Dep-estradiol Cypionate, up to 5 mg	5	7/1/2018
J1040	Injection, Methylprednisolone Acetate, 80 mg	51	7/1/2018
J1559	Injection, Immune Globulin (Hizentra), 100 mg	536	7/1/2018
J1580	Injection, Garamycin, Gentamicin up to 80 mg	17	7/1/2018
J1726	Injection, Hydroxyprogesterone Caproate, (Makena), 10 mg	100	7/1/2018
J2543	Injection, Piperacillin Sodium/Tazobactam Sodium, 1 gram/0.125 grams (1.125 grams)	24	7/1/2018
J2675	Injection, Progesterone, per 50 mg	10	7/1/2018
J2790	Injection, RHO (D) Immune Globulin, Human, Full Dose, 300 mg	5	7/1/2018
J3370	Injection, Vancomycin HCL, 500 mg	25	7/1/2018
J3475	Injection, Magnesium Sulfate, per 500 mg	200	7/1/2018
J3590	Injection, Unclassified biologics	None	7/1/2018
J7178	Injection, Human Fibrinogen Concentrate, not otherwise specified, 1 mg	9,900	7/1/2018
J7179	Injection, Von Willebrand Factor (Recombinant), (Vonvendi), 1 IU VWF:RCO	27,300	7/1/2018
J7180	Injection, Factor XIII (Antihemophilic Factor, Human), per 1 IU	7,000	7/1/2018
J7181	Injection, Factor XIII A-subunit, (Recombinant), per 1 IU	5,000	7/1/2018
J7183	Injection, Von Willebrand Factor Complex (Human), Wilate, 1 IU VWF:RCO	16,500	7/1/2018
J7186	Injection, Antihemophilic Factor VIII/Von Willebrand Factor Complex (Human), per factor VIII IU	50,000	7/1/2018
J7187	Injection, Von Willebrand Factor Complex (Humate-P), per IU VWF:RCO	36,000	7/1/2018
J7188	Injection, Factor VIII (Antihemophilic Factor, Recombinant), (Obizur), per IU	161,000	7/1/2018
J7189	Injection, Factor VIIA (Antihemophilic Factor, Recombinant), per 1 microgram	145,000	7/1/2018
J7190	Injection, Factor VIII (Antihemophilic Factor, Human) per IU	33,500	7/1/2018
J7192	Injection, Factor VIII (Antihemophilic Factor, Recombinant) per IU, noc	31,000	7/1/2018
J7193	Injection, Factor IX (Antihemophilic Factor, Purified, non-recombinant), per IU	27,000	7/1/2018
J7194	Injection, Factor IX, Complex, per IU	20,500	7/1/2018
J7195	Injection, Factor IX (Antihemophilic Factor, Recombinant) per IU, nos	35,000	7/1/2018
J7198	Injection, Anti-inhibitor, per IU	27,000	7/1/2018
J7200	Injection, Factor IX (Antihemophilic Factor, Recombinant), Rixubis, per IU	40,250	7/1/2018
J7201	Injection, Factor IX, FC Fusion Protein (Recombinant), per IU	27,000	7/1/2018
J7202	Injection, Factor IX, Albumin Fusion Protein, (Recombinant), Idelvion, 1 IU	13,500	7/1/2018
J7205	Injection, Factor III FC Fusion (Recombinant), per IU	28,250	7/1/2018
J7207	Injection, Factor VIII (Antihemophilic Factor, Recombinant) Pegylated, 1 IU	24,250	7/1/2018
J7209	Injection, Factor VIII, (Antihemophilic Factor, Recombinant), (NUWIQ), 1 IU	26,500	7/1/2018
J9060	Injection, Cisplatin, powder or solution, 10 mg	54	7/1/2018
J9260	Injection, Methotrexate sodium, 50 mg	798	7/1/2018
Q9966	Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml	350	7/1/2018
V2520	Contact Lens Hydrophilic, Spherical, per lens	None	7/1/2018
V2521	Contact Lens Hydrophilic, Toric, or Prism Ballast, per lens	None	7/1/2018
V2522	Contact Lens Hydrophilic, Bifocal, per lens	None	7/1/2018
V2523	Contact Lens Hydrophilic, Extended wear, per lens	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, 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

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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