Part B Insider - 2008 Issue 4
CMS Expands Medically Unlikely Edits for the New Year
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Article Overview
This article covers CMS’s expansion of medically unlikely edits, including the shift from purely anatomical scenarios to broader clinical-judgment review, and the introduction of a new HCPCS modifier intended to address certain denials. It also discusses why providers may not know which services are subject to these edits, how EOB remark indicators may help flag affected claims, and why the topic matters to coding and billing staff handling Medicare and physician claims.
Why This Topic Matters
Understanding these changes helps practices anticipate claim denials, review unit limits, and monitor remittance advice for indicators that a claim may have been affected by medically unlikely edits.
Article Sections
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MUE expansion and how the edits work
Introduces the upcoming expansion of CMS medically unlikely edits and describes the general shift in the types of scenarios they may target. It also discusses the operational reason these edits exist in claims processing.
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New modifier and related claim review issues
Covers the new HCPCS modifier introduced for the new year and the broader issue of identifying claims that may be affected by the edits. It also discusses review of remittance or EOB indicators tied to these denials.
What You Will Learn
- How CMS is broadening the scope of medically unlikely edits
- Why a new modifier is being introduced in connection with these edits
- What kinds of claim-review and EOB-monitoring issues practices should watch for
- Why the list of affected services remains a concern for providers
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Physician office staff
- Compliance teams
Codes Discussed
Modifiers Discussed
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