(Medicare Claims Processing Manual)

c. Modifier 59 or XU is used appropriately for a diagnostic procedure, which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow -up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non- surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure  and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post -procedure  diagnostic procedure is an inherent component or otherwise included (or not separately payable) post -procedure service of the surgical procedure or non -surgical therapeutic procedure, it should not be reported separately.   5. Modifiers 59 or X{EPSU} are used inappropriately if the basis for their use is that the     narrative description of the 2 codes is different.   C. Modifier 91 Modifier 91 may be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day when appropriate. If a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, (i.e., MAI equal to 1) appropriate use of CPT modifiers (i.e., 59 or - X{EPSU}, 76, 77, 91, anatomic) may be used to report the same HCPCS/CPT code on separate lines of a claim. This modifier indicates to the Medicare contractors that the physician had to perform a repeat clinical diagnostic lab oratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. This modifier must not be used to report repeat laboratory testi ng due to laboratory errors, quality control, or confirmation of results. For example, if a laboratory performs all tests included in a panel of laboratory tests and repeats one of these component tests as a medically reasonable and necessary service on the same date of service, the HCPCS code corresponding to the repeat laborat ory test may be reported with modifier 91 appended.  D. Reserved for future use  E. Coding for Noncovered Services and Services Not Reasonable and Necessary  For information on this topic, see the Claims Processing Manual Chapter 1 and MLN Booklet: Medicare Advance Written Notices of Noncoverage ICN 006266 found on the CMS website at: MLN Booklet: Medicare Advance Written Notices of Noncoverage ICN 006266. Use of the A9270  A9270, Noncovered item or service, will not be accepted under any circumstances for services or items billed to A/B MACs. However, in cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the A9270 must continue to be used by suppliers to bill DME MACs for statutorily non- covered items or supplies and items or supplies that do not meet the definition of a Medicare benefit. Claims Processing Instructions  At A/B MAC and DME MAC discretion, claims submitted using the GY modifier may be auto-denied. If the GZ and GA modifiers are submitted for the same item or service, treat the item or service as having an invalid modifier and therefore unprocessable. Effective for dates of service on and after July 1, 2011, A/B MACs shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs shall not perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make all language published in educational outreach materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review.  20.9.2 - Reserved for future use  (Rev. 4465; Issued: 11- 15-19, Effective: 01 -30-19, Implementation: 01- 30-19) 20.9.3  Appeals     (Rev. 10878, Issued: 07 -15-2021, Effective:08- 16-2021; Implementation:08 -16-2021)           When a request for review is received as a result of an initial determination based on a correct coding initiative edit, and after determining that the reviews were coded correctly, the reviewer must come to the same conclusion as the initial determination  (i.e., the review does not result in an increase in payment). If the review determines that a correct coding modifier not submitted with the initial claim could have been appended to either code of an edit code pair, the reviewer may change the initial determination only if the correct coding initiative edit has a modifier indicator of 1. If the correct coding initiative edit modifier indicator is a 0, the reviewer must come to the same conclusion as the initial determination. If the conclusion is the same as the initial determination, the review determination must repeat the generic language that appears in the Medicare Summary Notice (MSN) or remittance advice notice pertaining to the correct coding edit. In addition, Medicare Administrative Contractors (MACs) must include the more detailed explanation of the correct coding initiative edit which can be found in the standard correspondence language for MACs in the Medicare Correspondence Language Manual  on the CMS NCCI Website.  20.9.3.1- Procedure -to-Procedure  (PTP) Edits                                                     (Rev. 10878, Issued: 07 -15-2021, Effective:08 -16-2021; Implementation:08 -16-2021)           All PTP edits have a Correct Coding Modifier Indicator (CCMI).  A denial of services due to a Procedure -to-Procedure (PTP) edit is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for Units of Service (UOS) denied based on a PTP. PTP edits with a CCMI of 0:  On appeal, if the CCMI is a 0, and the provider or supplier coded the claim correctly, there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider or supplier. If t he reviewer determines that the claim was coded incorrectly then, the review determination must repeat the generic language that appears in the MSN or remittance advice notice pertaining to the National Correct Coding Initiative (NCCI) edit. In addition, M edicare Administrative Contractors (MACs) must include the more detailed explanation of the NCCI edit, which can be found in the standard correspondence language for MACs in the Correspondence Language Manual for Medicare Services.  PTP edits with a CCMI of 1:  On appeal, if the correct coding initiative edit modifier indicator is a 1, the reviewer must determine whether the claim was coded correctly. For example, the reviewer should determine whether the provider or supplier reported an incorrect code, a medic ally unnecessary service, or simply neglected to use a modifier. The reviewer may change the initial determination only if the correct coding initiative edit has a modifier indicator of 1 and the reviewer determines that an NCCI -associated modifier could  have been appended to either code of a correctly coded edit code pair. If the reviewer determines that the claim was coded incorrectly then, the review determination must repeat the generic language that appears in the Medicare Summary Notice (MSN) or rem ittance advice notice pertaining to the NCCI edit. In addition, MACs must include the more detailed explanation of the NCCI edit, which can be found in the standard correspondence language for MACs in the Correspondence Language Manual for Medicare Services.  20.9.3.2- Medically Unlikely Edits  (MUEs)  (Rev.  10878, Issued: 07 -15-2021, Effective:08 -16-2021; Implementation:08 -16-2021)           All Healthcare Common Procedure Coding System (HCPCS) codes with Medically Unlikely Edit (MUE) values have an MUE adjudication indicator (MAI).  MUEs for HCPCS codes with an MAI of 1:  MUEs for HCPCS codes with an MAI of 1 will be adjudicated as a claim line edit.  MUEs for HCPCS codes with an MAI of 2:  MUEs for HCPCS codes with an MAI of 2: MUEs for HCPCS codes with an MAI of 2 are absolute date of service edits. These are per day edits based on policy.   HCPCS codes with an MAI of 2 have been rigorously reviewed and vetted within CMS and obtain t his MAI designation because units of service (UOS) on the same date of service in excess of the MUE value would be considered contrary to statute, regulation, or subregulatory guidance. Subregulatory guidance includes clear correct coding policy that is bi nding on both providers or suppliers and the Medicare Administrative Contractors (MACs). As stated in CR 8853, while Qualified Independent Contractors (QICs) are not bound by subregulatory guidance, they should understand the policy nature of the MAI 2 i ndicator when considering whether to pay UOS in excess of the MUE value if claim denials based on these edits are appealed.   Limitations created by anatomical or coding restrictions are incorporated in correct coding policy, both in the Health Insurance Portability & Accountability Act of 1996 (HIPAA) mandated coding descriptors and CMS approved coding guidance as well as specif ic guidance in the CMS and National Correct Coding Initiative (NCCI) Policy manuals. For example, it would be contrary to correct coding policy to report more than 1 unit of service for "ventilation assist and management . . . initial day" because such usa ge could not accurately describe 2 initial days of management occurring on the same date of service as would be required by the code descriptor.  The CMS establishes edits with an MAI of 2 based directly on regulation, statute or subregulatory guidance.  MUEs for HCPCS codes with an MAI of 3:  MUEs for HCPCS codes with an 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 revie w) 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 eff ectuation instructions from a reconsideration or higher level appeal.  General Instructions on MUEs:   MUEs are set high enough to allow for medically likely daily frequencies of services provided in most settings. Because MUEs are based on current coding instructions and practices, MUEs are prospective edits applicable to the time period for which the edit  is effective. A change in an MUE is not retroactive and has no bearing on prior services unless specifically updated with a retroactive effective date. In the unusual case of a retroactive MUE change, MACs are not expected to identify claims but should re open impacted claims that providers or suppliers bring to their attention.    Since MUEs are auto -deny edits, denials may be appealed. Appeals shall be submitted to the appropriate MAC not the NCCI contractor. MACs adjudicating an appeal for a claim denial for a HCPCS code with an MAI of 1 or 3 may pay correctly coded correctly counted medically necessary UOS in excess of the MUE value.    A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening or redetermination medical records are provided with respect to an MUE denial for an edit with an MAI of 3, MACs will review the records to determine if the provider or 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 determin ation that the item/service is not reasonable and necessary under section 1862(a)(1)). This may also be true for certain edits with an MAI of 1. The CMS interprets the notice delivery requirements under Section1879 of the Social Security Act (the Act) as  applying to situations in which a provider or supplier expects the initial claim determination to be a reasonable and necessary denial. Consistent with NCCI program guidance, denials resulting from MUEs are not based on any of the statutory provisions tha t give liability protection to beneficiaries under section 1879 of the Social Security Act. Thus, ABN issuance based on an MUE is NOT appropriate. A provider or supplier may not issue an ABN in connection with services denied due to an MUE and cannot bill the beneficiary for UOS denied based on an MUE.