Medicare Compliance & Reimbursement

Question: Is it ever appropriate to fill out an advance beneficiary notice (ABN) form for a service that has already been denied due to a medically unlikely edit (MUE)?

Texas Subscriber

Answer: Probably not. An ABN should be used to alert a beneficiary that a service or item may not be covered by Medicare.

And according to the Centers for Medicare & Medicaid Services (CMS), an MUE is “the maximum units of service (UOS) reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.” The agency notes that not all HCPCS/CPT^® codes have an MUE.  

Additionally, CMS explains that it wouldn’t be appropriate to send out an ABN based on an MUE. CMS says: “A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an ABN doesn’t shift liability to the beneficiary for [units of service] UOS denied based on an MUE.”

If a situation arises where UOS are indeed provided but the services were possibly not medically reasonable or necessary, then the reason for a denial may be warranted, CMS says. But the agency is explicit in saying that the ABNs are related to medical necessity denials and MUEs are related to coding denials.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC