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April 2013

New message for daily quantity maximums

Starting as early as this June, providers will receive a new message when a submitted HCPCS or CPT procedure code reaches or exceeds its recommended daily quantity maximum.

This maximum determines the number of times a procedure can be billed on a single claim line for a particular date. Currently, there is no outpatient facility message when this daily maximum is reached or exceeded.

When a maximum quantity is reached, this message will alert providers that they only will be reimbursed for the daily maximum quantity. For example, if the maximum is five per day for a reported HCPCS or CPT code, but 15 are submitted, the message will state that there’s been an adjustment in the reimbursement. Payment will be made for the first five only.

Web-DENIS will display claims information with both the paid and maximum quantities.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
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