AHA Coding Clinic® for HCPCS - 2009 Issue 2; FOR your INFORMATION

Inappropriate use of an advanced beneficiary notice (ABN) with medically unlikely edits (MUE) denials

On December 8, 2006, the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 5402, stating “Finally, excess charges due to units of service greater than the MUE may not be billed to the beneficiary (this is a “provider liability”) (sic), and this provision can neither be waived nor subject to an Advanced Beneficiary Notice (ABN). This information has not changed. An MUE denial is an initial determination based on a coding denial, not a medical necessity denial. By statue an ABN may be applied only if the initial determination on a claim results...

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