Providers sometimes run into trouble when billing Current Procedural Terminology (CPT) Code 97750. Providers use this procedure code to bill for functional capacity exams, including physical performance tests and measurements, with written reports. However, a pesky Medically Unlikely Edit (MUE) complicates the matter by limiting the number of billable units.

Knowing the limits MUEs impose on codes like CPT 97750 is key to accurate billing.

MUE 101

Per California Code of Regulations (CCR) Section 9789.12.13, California adopted Medicare’s National Correct Coding Initiative (NCCI) and “medically unlikely” edits, or MUEs, effective January 2014. NCCI edits adjust reimbursement for certain combinations of procedure codes, while MUEs put a cap on the number of units for which a provider can bill for certain codes.

In short, MUEs exist because Medicare determined that — in most cases — there’s no need to provide more than a certain number of units for some procedures, and California workers’ compensation followed suit.

As a result, California providers are sometimes surprised to receive Explanations of Review (EORs) that deny or modify charges citing an MUE. MUEs fall into two categories:

• Bill Line Edits: If any given bill line exceeds the maximum number of allowable units, the claims administrator may deny all units for that line.
  
• Date of Service Edits: If the bill features the same code on separate lines, but still exceeds the maximum number of allowable units per day, the claims administrator may deny all units for the date of service.

There are certain rare exceptions to MUEs. Just because a given number of units is “unlikely” doesn’t mean it’s impossible! In some very limited circumstances, providers may use modifiers to justify units exceeding the MUE value, including:

• 76 (repeat procedure by same physician)
• 77 (repeat procedure by another physician)
• anatomic modifiers (e.g., RT, LT, F1, F2)
• 91 (repeat clinical diagnostic laboratory test)
• 59 (distinct procedural service); not that providers may only utilize modifier 59 if no other appropriate modifier describes the service.

Bear in mind that the only ironclad way to obtain reimbursement for units billed in excess of MUE allowable units is to procure a signed agreement with the employer or insurer’s claims administrator.

All MUEs are published on the CMS website for provider reference.

MUE for 97750

In the case of CPT 97750, the Centers for Medicare and Medicaid Services (CMS) determined that physicians are “unlikely” to need more than 2 hours to perform and report functional capacity tests for a given patient on any single day.

Units of service for 97750 are 15 minutes each; thus the maximum number of billable units is 8.

This MUE, which CMS rationalizes based on clinical data, went into effect July 1, 2016, and remains in effect today. As such, if a  provider bills for more than 2 hours, or 8 units, worth of CPT 97750, the claims administrator will likely deny payment for every 99750 unit on the bill.

To ensure proper reimbursement, providers should only bill for 8 units of service or fewer for CPT 97750 on any date of service.

If for some reason an extraordinary — or “unlikely” —  medical necessity makes more functional capacity testing necessary, we recommend procuring a signed agreement with the employer or insurer’s claims administrator; the modifiers mentioned above are not likely applicable to 99750.

Absent a signed agreement, In the event that your office receives an EOR denying payment due to MUE for 97750, we recommend submitting a request for second review. The second review should explain the error, and requests payment for the maximum allowable 8 units.

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