Adhering to UHC’s MUE guidelines, improving documentation, and reviewing appeals can help pathology labs boost reimbursement.
A recurring issue that was highlighted at the recent American Pathology Foundation (APF) National Meeting in Rutherford, NJ was the difficulty in billing United Healthcare (UHC) for multiple units of CPT codes 88342 and 88341, where claims are frequently denied. Pathologists are encountering challenges when submitting claims for multiple units of these codes, even when proper testing procedures are followed. This has led some to explore alternative approaches, like switching modifiers or adjusting how tests are processed.
The Modifier Dilemma: "59" vs. "XU"
One common practice to overcome UHC denials has been switching modifiers from "59" to "XU" to distinguish the procedural differences between services. The "59" modifier is used to indicate that a service or procedure was distinct or independent from other services performed on the same day. Meanwhile, "XU" (used for unusual non-overlapping services) is sometimes employed in an attempt to meet payer guidelines more effectively. However, even with this approach, many pathologists still find themselves facing claim denials.
To add to the complexity, some labs have delayed processing the tests to avoid submitting multiple units on the same day, hoping to bypass the restriction on frequency. This may alleviate denials in the short term, but it's not a sustainable or optimal solution.
Understanding the MUE Reimbursement Policy
To navigate these challenges, it's critical to be familiar with UHC’s Maximum Frequency Per Day (MUE) policy for commercial payers. This policy outlines the number of units allowed per day for specific CPT codes, including 88342 and 88341. The UHC MUE-Reimbursement policy can be reviewed here.
Understanding and adhering to the number of units allowed per day can help ensure compliance and reduce the likelihood of denials. For instance, if UHC limits the number of units for 88342 to a specific number per day, submitting claims in accordance with this limit can increase approval rates.
Better Documentation for Appeals
During the APF meeting, it was suggested that pathologists could strengthen their documentation to improve the appeals process. Specifically, the path report should clearly document the need for multiple units of 88342 and 88341, providing detailed justifications for each unit billed. This level of detail can be crucial when submitting an appeal, as it helps clarify the medical necessity and unique circumstances that warrant multiple units.
Tracking Appeal Success
Quadax pulls appeals data to assess UHC’s current behavior regarding these denials. Analysis provides valuable insights into how successful appeals have been when using the “59” modifier. Tracking your appeal success with UHC is important and if you are not seeing success then you need to reach out to your Provider Advocate. Your Provider Advocate can help with the claims reimbursement process and appeal issues. For support and reference see UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage.
Key Takeaways for Pathology Labs:
- Understand UHC’s MUE Policy: Familiarize yourself with the maximum frequency limits for CPT codes 88342 and 88341 to avoid billing errors and subsequent denials.
- Modifiers Matter: Be mindful when selecting between modifiers "59" and "XU" to ensure compliance with payer-specific requirements. Modifiers play a crucial role in distinguishing distinct services.
- Strengthen Documentation: Detailed and thorough documentation on pathology reports is essential for improving the success of appeals.
- Monitor Appeal Trends: Gathering data on appeal success rates can help identify patterns and improve future claim submissions.
By adhering to UHC’s MUE guidelines, improving documentation practices, and analyzing appeal outcomes, pathology labs can better navigate the billing landscape for CPT codes 88342 and 88341 and improve their chances of receiving appropriate reimbursement. Quadax will continue to provide updates as we monitor these trends. Click here to subscribe.
