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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Article Overview
This article discusses Medicare guidance from CMS on the relationship between Advanced Beneficiary Notices and medically unlikely edit denials. It explains the policy context, references related CMS and NCCI materials, and is aimed at readers who need to understand compliance boundaries around beneficiary billing when claims are denied for coding-related reasons.
Why This Topic Matters
It helps billing and coding professionals interpret CMS guidance on when beneficiary liability notices are not appropriate in the context of MUE-related denials and appeals.
What You Will Learn
- How CMS guidance addresses ABN use in relation to MUE denials
- The distinction between coding denials and medical necessity denials in this context
- How related CMS and NCCI policy materials are referenced in the article
- Why appeals do not change the underlying ABN limitation described in the guidance
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Revenue cycle teams
- Medicare providers
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