Advance Beneficiary Notice (ABN) with Medically Unlikely Edits (MUE) Denials
CMS has recently published guidelines regarding balance billing when dealing with denials based on the Medically Unlikely Edits. I have contacted Dr. Niles Rosen, the Medical Director of the Medically Unlikely Edit (MUE) Program and National Correct Coding Initiative (CCI) at Correct Coding Solutions in Indianapolis. Dr. Rosen has agreed that the following interpretation of this edict issued by CMS is correct.
Under no circumstances can a physician balance bill (through an Advanced Beneficiary Notice) a Medicare patient for care provided for a specific procedure that exceeds the number of units of service (UOS) listed in the MUE database.
For example, the MUE for metacarpal fractures is four. If you treat a patient for five metacarpal fractures you cannot balance bill the patient for the fifth metacarpal fracture care. However, the – 59 modifier can be used in this situation. The following coding can be used in this situation.
(26615 Open treatment metacarpal fracture, single includes internal fixation, when performed, each bone)
Dr. Rosen has indicated that if the claims processing contractor’s processing system is not processing correctly, CMS through Correct Coding Solutions would be interested in knowing about such problems, so please contact them if you have something to report.
I hope this explanation will help you in dealing with any denials based on the MUEs.