Radiology Question for the Week of April 3, 2023

Question:

If duplex exams of both an upper and a lower extremity are ordered and performed at the same encounter, would it be appropriate to report CPT code 93971 twice even though that code has an MUE of 1?

Answer:

A. If both exams are medically necessary, ordered, and performed, CPT® 93971 x2 would be appropriate. Report once for the left lower extremity, and once again for the left upper extremity (same DOS, same performing provider). Regarding modifier assignment, which will vary by payer. Each payer can make and apply their own policy rules. Some may direct to utilize 76 (repeat procedure or service by the same physician) on the 2nd line item. Others may require 59 (distinct procedural service) or an X_ subset option on the 2nd line item. As noted, CPT code 93971 has a MUE of 1, MAI 3 per CMS. The MAI 3 (Date of Service) edit signifies that it may be appealed. MACs may pay UOS in excess of the MUE value but will require additional documentation to support medical necessity. Be sure to verify with your MAC to see how they will address this situation. It may also be beneficial to validate commercial insurance contracts as well and monitor claims closely for any denial issues. The American College of Radiology (ACR) Economics Commission has been actively engaged in this issue and has repeatedly engaged with CMS to increase the MUE value, especially in response to the Covid-19 pandemic. While CMS has remained firm to date, continued advocacy from providers may help promote a future change to align more closely with clinical practice.

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