Providers sometimes run into trouble when billing Current Procedural Terminology (CPT) Code 97750. Providers use this procedure code to bill for functional capacity exams, including physical performance tests and measurements, with written reports. However, a pesky Medically Unlikely Edit (MUE) complicates the matter by limiting the number of billable units. Knowing the limits MUEs impose on codes like CPT 97750 is key to accurate billing.
There are certain rare exceptions to MUEs. Just because a given number of units is “unlikely” doesn’t mean it’s impossible! In some very limited circumstances, providers may use modifiers to justify units exceeding the MUE value, including:
Bear in mind that the only ironclad way to obtain reimbursement for units billed in excess of MUE allowable units is to procure a signed agreement with the employer or insurer’s claims administrator.
All MUEs are published on the CMS website for provider reference.
In the case of CPT 97750, the Centers for Medicare and Medicaid Services (CMS) determined that physicians are “unlikely” to need more than 2 hours to perform and report functional capacity tests for a given patient on any single day.
Units of service for 97750 are 15 minutes each; thus the maximum number of billable units is 8.
This MUE, which CMS rationalizes based on clinical data, went into effect July 1, 2016, and remains in effect today. As such, if a provider bills for more than 2 hours, or 8 units, worth of CPT 97750, the claims administrator will likely deny payment for every 99750 unit on the bill.
To ensure proper reimbursement, providers should only bill for 8 units of service or fewer for CPT 97750 on any date of service.
If for some reason an extraordinary — or “unlikely” — medical necessity makes more functional capacity testing necessary, we recommend procuring a signed agreement with the employer or insurer’s claims administrator; the modifiers mentioned above are not likely applicable to 99750.
Absent a signed agreement, In the event that your office receives an EOR denying payment due to MUE for 97750, we recommend submitting a request for second review. The second review should explain the error, and requests payment for the maximum allowable 8 units .
