Mental Health Medically Unlikely Edit (MUE)

The Centers for Medicare & Medicaid Services (CMS) has identified an incorrect Medically Unlikely Edit (MUE) of 3 units for hospital outpatient services described by Current Procedural Terminology (CPT) Code 90853 (Group psychotherapy (other than of a multiple-family group)). The proper MUE for this code is 5 units. This will be retroactively corrected in the January 1, 2010 Release. Your FI/MAC will hold hospital outpatient claims (Type of Bill (TOB) 13X) with 4 or 5 units of CPT Code 90853 on one line with dates of service on or after October 1, 2009.

However, when providing 4 or 5 units of the service described by CPT Code 90853 between October 1, 2009, and January 1, 2010, you may choose to bill 3 units of CPT Code 90853 on one line, and 1 or 2 units of CPT Code 90853 on another line with Modifier -59 in order to receive payment for these services prior to the implementation of the corrected MUE on January 1, 2010. This is a time-limited instruction and applies only to services described by CPT Code 90853 provided between October 1, 2009, and January 1, 2010. In all other cases, the use of Modifier -59 is reserved only for services provided in distinct clinical circumstances. It is improper to use Modifier -59 to circumvent MUEs unless specifically instructed by your FI/MAC to do so.

Page Last Updated: Tuesday, 10-Nov-2009 07:38:33 CST