Description
Beginning with dates of service on and after January 1, 2007, it has been determined that all line items on the claim have units of service that are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary and this provision can neither be waived nor subject to an advanced beneficiary notification (ABN). Note: this reason code is assigned effective for claims received on or after April 1, 2010.

Resolution
Units at claim level are billed in excess for the allowable units based on the National Correct Coding Initiative (NCCI) edits for Medically Unlikely Edits (MUE). If the units of service can be justified, a Redetermination may be submitted. Redetermination should include:

  • All applicable supporting medical documentation
  • Corrected UB-04 form

If the excessive units were submitted in error, a Redetermination may be submitted. Note: Redeterminations will only review medically denied lines.

Resources

Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department


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