The purpose of this policy is to reimburse units billed for outpatient hospital services without reimbursing for obvious billing submission and data entry errors or incorrect coding based on anatomic considerations, Healthcare Common Procedure Coding System II (HCPCS)/Current Procedural Terminology CPT® (CPT) code descriptors, CPT coding instructions, established UnitedHealthcare policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment. The term “units” refers to the number of times services with the same CPT or HCPCS codes are provided per day by the same outpatient hospital. UnitedHealthcare has established Maximum Frequency per Day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service. Reimbursement also may be subject to the application of other UnitedHealthcare Reimbursement policies and/or Provider contracts. This policy applies whether an outpatient hospital submits one CPT or HCPCS code with multiple units on a single claim line or multiple claim lines with one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted with multiple units.
MFD values will be evaluated and/or updated quarterly to reflect new, changed, and deleted codes. Review of MFD values for existing CPT and HCPCS codes based on criteria within this policy will be completed quarterly.
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