MEDICALLY UNLIKELY EDITS: Prepare For A Whole New Wave Of Denials In January

Article Overview

This article covers an upcoming expansion of Medicare medically unlikely edits and the move from anatomy-based limits toward clinical judgment-based limits. It is relevant to coders, billing staff, compliance teams, and physician practices that work with CPT and HCPCS claims and need to monitor denial risk, remittance notices, and carrier guidance. The article also discusses how the changes were being developed, why the list of edits was not made public, and what to watch for on explanation of benefits statements.