Don’t bill the patient if denial is due to medically unlikely edit

Article Overview

This article reviews a Medicare policy clarification affecting denials tied to medically unlikely edits and how those denials relate to beneficiary billing and advance beneficiary notices. It is aimed at coding and billing professionals who work with Medicare claims, especially those using CPT and HCPCS Level II codes for physician services, drugs, supplies, and durable medical equipment. The discussion centers on the policy update, supporting CMS transmittal language, and the practical implications for claim handling and appeals.