Medically Unlikely Edits Deviations

Policy ID: NDRP-GC-017

Section: General Coding

Effective Date: July 01, 2018

Revised Date: April 01, 2022

Last Reviewed: April 01, 2022

Applies To: Commercial and Medicaid Expansion

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

8/1/2020

90834

Psychotherapy, 45 minutes with patient

8/1/2020

90837

Psychotherapy, 60 minutes with patient

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

1/1/2019

96139

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

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.

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.

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

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.

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.

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.

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

J0202

Injection, Alemtuzumab, 1 mg

7/1/2018

J0295

Injection, Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm

7/1/2018

J0461

Injection, Atropine Sulfate, 0.01 mg

100,000

7/1/2018

J0690

Injection, Cefazolin Sodium, 500 mg

7/1/2018

J0696

Injection, Ceftriaxone Sodium, per 250 mg

7/1/2018

J0743

Injection, Cilastatin sodium, Imipenem, per 250 mg

7/1/2018

J0744

Injection, Ciprofloxacin for intravenous infusion, 200 mg

7/1/2018

J0878

Injection, Daptomycin, 1 mg

2,000

7/1/2018

J1000

Injection, Dep-estradiol Cypionate, up to 5 mg

7/1/2018

J1040

Injection, Methylprednisolone Acetate, 80 mg

7/1/2018

J1559

Injection, Immune Globulin (Hizentra), 100 mg

536

7/1/2018

J1580

Injection, Garamycin, Gentamicin up to 80 mg

7/1/2018

J1726

Injection, Hydroxyprogesterone Caproate, (Makena), 10 mg

100

7/1/2018

J2426

Injection, paliperidone palmitate extended release, 1 mg

234

4/1/2022

J2543

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

7/1/2018

J2675

Injection, Progesterone, per 50 mg

7/1/2018

J2790

Injection, RHO (D) Immune Globulin, Human, Full Dose, 300 mg

7/1/2018

J3370

Injection, Vancomycin HCL, 500 mg

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

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

4/1/2022

Added J2426 MUE deviation effective 4/1/2022.

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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