decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 7 (July)
Don’t bill the patient if denial is due to medically unlikely edit
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Article Overview
This article covers a Medicare clarification regarding denials based on medically unlikely edits and how that affects billing the beneficiary. It is aimed at coders, billing staff, compliance personnel, and practices that work with Medicare claims, especially those using CPT and HCPCS Level II services. The discussion references an update to the National Correct Coding Initiative manual, an accompanying letter to the AMA, and a CMS transmittal that together explain the policy change and its relationship to advance beneficiary notices and appeals.
Why This Topic Matters
The article matters because it addresses when a beneficiary may not be billed after a Medicare coding denial, which affects claim handling, patient billing practices, and compliance. It also highlights a mid-year policy clarification that affects how organizations interpret and respond to these denials.
What You Will Learn
- How Medicare characterizes denials related to medically unlikely edits
- How the policy update affects beneficiary billing and advance beneficiary notices
- What general types of claims and services are affected by medically unlikely edits
- How the clarification relates to the Correct Coding Initiative manual and CMS guidance
- What options remain available for appealing denied claims
Who Should Read This
- Medical coders
- Billing staff
- Compliance officers
- Physician practices
- Medicare billers
- Revenue cycle professionals
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