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Medically Unlikely Edits and CPT Code 97750

Medically Unlikely Edits and CPT Code 97750

Medically Unlikely Edits and CPT Code 97750 questions? Call (949) 863-0022 for answers!

Medical billing for physical performance testing is an area where many doctors get frustrated due to claim denials. This is usually because of coding errors and misunderstandings around the “eight-minute rule” and MUEs.

Current Procedural Terminology (CPT) Code 97750 is the procedure code to bill for functional capacity exams, including physical performance tests and measurements, and includes the writing of reports. Examples of exams includes isokinetic testing, timed up and go test, dynamic gait index, static back endurance, and Berg balance.

A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit (.pdf document) applied to medical claims against a procedure code for medical services rendered by one provider to one patient on one day. They represent the maximum number of units that require further documentation to support.

As the Centers for Medicare and Medicaid Services (CMS) does not publish all MUE values that are 4 or higher because of concerns about fraud and abuse, you should know that the maximum number of billable units for CPT Code 97750 is 8. This means you can bill for at total of 2 hours of service at 15 minutes per service unit.

Of course, everything doesn’t fit neatly into 15-minute increments. If your reporting shows an increment of less than eight minutes, you can not bill Medicare for it.

If your testing and reports have exceeded the two hours of MUE allowable units, or if you plan to perform additional exams under code 97750 in the same month, we recommend get a signed agreement with the employer or insurer’s claims administrator.

Given that the 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, there is some wiggle room with this code. If your office receives an EOR denying payment due to MUE for 97750, it is suggested you submit a request for second review.

Does your practice, doctor’s group or hospital have questions about Medical Unlikely Edits and CPT Code 97750? Call the medical billing experts at MBC Systems at (949) 863-0022 and learn how they can help.