Frequently Asked Questions

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Top Questions

What is the definition of "new patient" for billing evaluation and management (E/M) services?
Interpret the phrase... (more)

How does Medicare pay for services delivered by non-participating providers?
For services and ... (more)

What is a Medically Unlikely Edit?
A MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Co... (more)

Who is eligible to receive an NPI?
The National Provider Identifier (NPI) was adopted and became effective May 23, 2007 as the standard unique health ident... (more)

What is the column 1/column 2 correct coding edit table?
The column 1/column 2 correct coding edit table contains two types of code pair edits. One type cont... (more)

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the healt...
Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of ... (more)

Who can enter medication orders in order to meet the measure for the computerized provider order entry (CPO...
As mentioned in 80 FR 62798, a medical s... (more)

Who pays the difference between what the provider charges and Medicare pays?
The provider has an ... (more)

What physician shared patient data sets are available?
The physician referral data linked below was provided as a response to a Freedom of Information Act (FOIA) request. The... (more)

How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit ...
For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, each line of a claim i... (more)

What is the difference between a legacy provider identifier (LPI) and a National Provider Identifier (NPI)?...
LPIs are any of a known set of identifie... (more)

What can count as a specialized registry?
A submission to a specialized registry may count if the rece... (more)

Which Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and f...
The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transa... (more)

I have a Drug Enforcement Administration (DEA) Number. Do I need a National Provider Identifier (NPI) as well?
The NPI does not replace the function of the DEA Number, which is to identify the prescriber of a co... (more)

What is the difference between a health plan and a payer?
A health plan (as defined in ... (more)

How are claims adjudicated with Medically Unlikely Edits (MUEs)?
Medically Unlikely Edits (MUEs) are either claim line edits or date of service (DOS) edits. If the MUE is a claim line e... (more)

What steps does a provider have to take to determine if there is a specialized registry available for them,...
The eligible professional (EP) is not required to make an exhaustive search of all potential registr... (more)

How do I change the laboratory director's name on my CLIA certificate of waiver?
You must notify the appropriate State Agency within 30 days about the change in the name of the director for your CLIA c... (more)

The billing provider on a claim is an eligible professional (EP) but the performing provider type is not an...
In establishing an encounter for purposes of patient volume, please see the regulations at 495.306(e... (more)

How should modifier 59 be reported under the National Correct Coding Initiative (NCCI) program?
Modifier 59 is used to indicate a "distinct procedural service". (See Modifier 59 article at ... (more)

Can hospitals bill Medicare for the lowest level ER visit for patients who check into the ER and are "triag...
No. The limited service provided to such... (more)

I entered numerator and denominator information during my Medicare Electronic Health Record (EHR) Incentive...
CMS does not plan to conduct an audit to find providers who relied on flawed software for their atte... (more)

Do Current Procedural Terminology (CPT) codes for psychological and neuropsychological tests include tests ...
Yes. Effective Janu... (more)

How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit ...
For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, ea... (more)

What does "column 2" mean in the column 1/column 2 correct coding edits table?
If the two codes of a National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edit pa... (more)

EHR Incentive Programs; What should a provider do in 2016 if they did not previously intend to report to a ...
... (more)

How do I obtain the National Correct Coding Initiative (NCCI) Policy Manual?
The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services may be obtained th... (more)

Are payments provided to a consulting firm or third party, whom in turn provide the payment (in whole or pa...
Yes, Open Payments requires reporting of both direct and indirect payments and other transfers of value provided by an a... (more)

Is the physician the only person who can enter information in the electronic health record (EHR) in order t...
The Stage 3 Final Rule for the Medicaid EHR incentive progra... (more)

What is HETS and how do I get connected to use this system?
The HIPAA Eligibility Transaction System (HETS) is intended ... (more)

What types of business structures are considered organization health care providers and thus eligible for o...
The NPI final rule defines “organization health care providers” as providers who are not individ... (more)

A number of measures for Meaningful Use objectives for eligible hospitals and critical access hospitals (CA...
There are two methods for calculating ED admissions for the ... (more)

Does CMS require updated physician (or non-physician practitioner) orders for lab, radiology services, or a...
CMS is not requiring the ordering provider to rewrite the or... (more)

In calculating the meaningful use objectives and measures for View, Download and Transmit, Secure Electroni...
The transitive effect applies to the View, Download and Transmit measure, Secure Electronic Messagin... (more)

How do I obtain a copy of my CLIA certificate?
To obtain a copy of your CLIA certificate, you should contact the appropriate State Agency. State Agency contact informa... (more)

Is there an appeal process for units of service (UOS) denied based on Medically Unlikely Edits (MUEs)?
Units of service (UOS) denied due to a Medically Unlikely Edit (MUE), whether a claim line MUE or da... (more)

What is the value-based payment modifier (Value Modifier) and who does it apply to?
The Affordable Care Act requires Medicare to establish a Value Modifier that provides for differential payment to a phys... (more)

Who are the current Medicare Administrative Contractors (MACs) for each Jurisdiction?
To find the current MACs and their contact information visit the website at: ... (more)

What are the supervision requirements for diagnostic psychological and neuropsychological tests?
Under the diagnostic test provision as a... (more)

What modifiers are allowed with the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) ...
The following modifiers are allowed with the National Correct Coding Initiative (NCCI) procedure to ... (more)

When eligible professionals work at more than one clinical site of practice, are they required to use data ...
CMS considers these two separate, but related issues. Meaningful use: Any eligible professional demo... (more)

What is the policy for measure calculation for actions outside of the EHR reporting period for the Medicar...
... (more)

Are expenses for diagnostic psychological and neuropsychological tests subject to the payment limitation fo...
In most cases, expenses for diagnostic p... (more)

What is the CMS Medically Unlikely Edit (MUE) program?
The CMS Medically Unlikely Edit (MUE) program was developed to reduce the paid claims error rate for... (more)

Starting with 2016 Open Payments data collection and reporting to CMS in 2017, are payments provided by an ...
Yes, the payment is reportable if the applicable manufacturer determines that the payment meets the definition of an ind... (more)