Radiology Question for the Week of October 31, 2016

Question:

Occasionally, when we have a patient for sentinel node localization, we inject both breasts. The radiopharmaceutical that we use, code A9520 (technetium tc-99m tilmanocept, diagnostic, up to 0.5 millicuries), has a medically unlikely edit (MUE) of 1. How can we get paid for both study doses?

Answer:

While the MUE is 1, the MUE adjudication indicator (MAI) is 3, which indicates that the MUE could be over-ridden if the procedure performed is medically appropriate. Depending on payer preference, you may be able to report A9520 once with modifier -50 (bilateral procedure) or twice with modifier -59 (distinct procedural service) or -76 (repeat procedure or service by same physician or other qualified healthcare professional) on one of the line items. Your Medicare contractor could still deny the second claim, but you could appeal with documentation to indicate why two doses were given.

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