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Question: Our lab is having issues billing for 88341, 88342, and 88360. Fairly regularly, we perform more than 13 units of 88341 with 88342 and 88360. We have been billing with modifier XU on 88341 and 88342 due to the National Correct Coding Initiative (NCCI) edits bundling into 88360. However, we then get a denial for all units of 88341 for medically unlikely edits (MUE). How should we bill this so we can get paid?

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Answer: The issue in this case does not lie in NCCI鈥檚 bundling 88341 (Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)) and 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) into 88360 (Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual).

While 88341 and 88342 are both column 2 codes for 88360, you can override the edit in the way you are doing by using an NCCI-associated modifier when appropriate, such as 59 (Distinct procedural service) or one of the following X{EPSU} modifiers:

• XE (Separate encounter 鈥�)
• XP (Separate practitioner 鈥�)
• XS (Separate structure 鈥�)
• XU (Unusual non-overlapping service 鈥�)

Instead, the issue lies in the MUE units assigned to 88341, which are 13 per date of service (DOS). If, as you say, you are regularly billing in excess of this amount, you may face a denial.

However, 88341 has an MUE adjudication indicator (MAI) of 鈥�3.鈥� This means Medicare will allow you to appeal the denial of units of service (UOS) over the MUE for the DOS based on medical necessity. For more information, you can consult the . This tells you that 鈥渃ontractors may pay UOS in excess of the MUE value if there is pre-payment adequate documentation of medical necessity or on appeal of the denied claim(s).鈥�

As a refresher, if the code has an MAI of 鈥�1,鈥� the code is adjudicated on a claim-line basis, meaning that you can鈥檛 exceed the number of MUE units on a claim line. An MAI of 鈥�2鈥� means that the frequency limit is absolute for a DOS, and you may not override the edit with a modifier. But an MAI of 鈥�3鈥� means that the frequency limit is based on the DOS, and Medicare will automatically deny any claims in excess of that limit, even if you use an appropriate modifier. However, Medicare will consider an appeal with appropriate documentation.

One way to do this is to split the overage onto a separate charge line. For example, for 15 units of 88341, you can bill 88341 x 13 on one line and 88341 x 2 on a second. However, you will need to provide records to justify this 鈥� for example, you can document that you are billing for distinct antibody stains.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC