Health Information Management

Tip: Train staff about appeals for medically unlikely edit denials

APCs Insider, May 7, 2010

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CMS now denies claim lines with units of service that exceed the medically unlikely edit (MUE) for that code. Previously, it either rejected these lines or returned them to the provider. Appealing a denial can result in additional proper reimbursement for a facility, but it also requires a time commitment from staff members.

Accurate, complete documentation will be important for successful appeal of MUE denials. Staff members may need to contact physicians to obtain additional information when documentation is insufficient.

Staff members need to know the different audits and appeals. They need to know the type of denial, whether they may appeal, and where the claim is in the appeal process. Most HIM departments are unable to add staff, so facilities must find an appeals process that works for their facility and staff members.

This tip is adapted from “Now on the to-track list: medically unlike edit appeals” in the May issue of Briefings on APCs.



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