Corporate Compliance

CMS’s Medically Unbelievable Edits lead to instant denial

Compliance Monitor, March 9, 2005

CMS announced March 1 in Medlearn Matters number 2987 that effective July 5, all Medicare physicians, providers, and suppliers billing Medicare fiscal intermediaries and carriers, including durable medical equipment regional carriers, will be subject to its Medically Unbelievable Edits.

As of the July 5, CMS will automatically deny claims for any services that exceed a specified number of service units per day through the use of its new edits, which were established in Change Request 2987.

According to Medlearn Matters, the edits analyze claims for the same

  • beneficiary
  • HCPCS code
  • dates of service
  • billing provider

The claims are tested against an established allowable number of units of service. Medicare will deny all billed units of service that exceed the allowable number on the basis that the service could not have been delivered.

CMS recommends that providers start to prepare for these new edits now to make sure your billing staff are aware of the edits and that you have a mechanism in place to ensure the accuracy of the daily units of service in your claims.

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