How Are Claims Adjudicated with Medically Unlikely Edits

When you talk about claims and how contractors process claims with regard to medically unlikely edits. CMS contractors adjudicate claims on a line by line basis for these edits. So, each line is looked at individually. For example, five of the 11446 - if you need to bill five of those, billing them on separate lines with the appropriate modifiers would be the way that you would need to do that in order to get paid. Anything outside of that, you're going to get - it's going to get caught up in that edit and is going to be denied. Now, there are other more appropriate ways to bill that particular service potentially as an unlisted service or with a modifier that indicates that it's more extensive than the code described. But, if it's a type of service that is perfectly described by the code billing that on individual lines with the appropriate modifiers then it is the way to go.

There are times when repetitive services are reported on a single line. And this is when a repetitive service across of date range occurs. For example, if you have multiple physical therapy - it's excluded from these edits. But, if you have a multiple modalities that are billed across an entire month of services - and so you have a unit of service value of 20, your unit of service are not on that single day, you need to have your date range in there. So, when you're billing for claims like that, make sure that your dates are correct if you're billing repetitive services on a single line across a span of day. So, if you don't do that type of billing, then don't worry about it. But if you are doing repetitive services across the date range, Medicare tells us that contractors are actually instructed to divide the unit of service by the number of days and then round it to the nearest total number and then that's how they compare for the medically unlikely edits.

So if you are doing only one a day in a medically unlikely edit, then you shouldn't have a problem as long as your dates are correct in you date range. So, it’s very important if you're doing those repetitive types of services. Also, another question that comes up with regard to these medically unlikely edits is – what happens if I'm denied or returned to provider for medically unlikely edit but I've had the patient sign an ABN? Shouldn't I be able to bill the patient then because the patient already signed an ABN? They know that they're going to be responsible.

Well, what CMS tells us - and actually is that a provider cannot bill the beneficiary for services that are denied due to a medically unlikely edit because what they are saying is the medically unlikely edit denial is a coding denial and not a medical necessity denial. If we're being hit with a medically unlikely edit it's because we haven't billed it properly. We haven't applied the appropriate modifiers and the appropriate code and so thereby, we cannot bill the patient secondary to having our ABN on file. So very important if you do have an ABN for any of these types of services and the denial that you receive is a medically unlikely edit denial, that is not something that you can pass on the patient.

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