Needing some guidance regarding reimbursement of this code. We use it to reflect TRAILS Social Skills which is a kind of hands on group. Typically the sessions are 2 hours long, thus we bill 8 units (since its a 15 minute code).
My issue is: The carriers that do pay only permit 4 units stating "The member’s plan provides coverage for charges that are reasonable and appropriate. This procedure exceeds the maximum number of services
allowed under our guidelines for a single date of service." When I inquire to show me the policy on max units for this code in their policy – they have nothing specific only that 4 is reasonable & appropriate. Does anyone know where I can find an MUE (Maximum Allowed Average) of sorts for this code? Or have suggestions on appealing it? Thoughts in general are welcome!!
My issue is: The carriers that do pay only permit 4 units stating "The member’s plan provides coverage for charges that are reasonable and appropriate. This procedure exceeds the maximum number of services
allowed under our guidelines for a single date of service." When I inquire to show me the policy on max units for this code in their policy – they have nothing specific only that 4 is reasonable & appropriate. Does anyone know where I can find an MUE (Maximum Allowed Average) of sorts for this code? Or have suggestions on appealing it? Thoughts in general are welcome!!