Frequently Asked Questions

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Top Questions

What is an IRS Form CP 575?
The IRS Form CP 575 is an Internal Revenue Service generated letter you receive from the IRS granting your Employer Iden... (more)

What is the definition of "new patient" for billing evaluation and management (E/M) services?
Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation an... (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 through the CMS websit... (more)

What physician referral data sets are publicly available?
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What is a Medically Unlikely Edit?
An MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Coding System (HCPCS)... (more)

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

[EHR Incentive Programs] Who can enter medication orders in order to meet the measure for the computerized ...
Any licensed healthcare professional can enter orders into the medical record fo... (more)

[Medicare EHR Incentive Program]  When reporting on the Summary of Care objective in the Medicare and ...
CMS is aware of difficulties related to systems issues that eligible professionals, eligible hospitals, and critical ... (more)

What modifiers are allowed with the National Correct Coding Initiative (NCCI) edits?
The following modifiers are allowed with the National Correct Coding Initiative (NCCI) edits: Anatomic mod... (more)

How do I report ICD-10 codes on claims when the dates of service span from prior to 10/1/2015 to on or afte...
Many payers are requiring claims with dates of service that span the October 1, 2015 implementation date to be split ... (more)

[EHR Incentive Programs] A number of measures for Meaningful Use objectives for eligible hospitals and crit...
                &nbs... (more)

What exactly does "column 1" mean in the column 1/column 2 correct coding edits table?
Formerly known as the "comprehensive code" within the column 1/column 2 correct coding edits table, the column 1 code ge... (more)

In current practice by the mental health field, many clinicians use the DSM-IV in diagnosing mental disorde...
Yes. It is expected that clinicians may continue to base their diagnostic decisions on the DSM-IV/DSM-5 criteria. In add... (more)

How do I enroll in Medicare?
Providers can enroll in Medicare by using either Internet-based PECOS located at ... (more)

What procedures and services are payable when performed in the Ambulatory Surgical Center (ASC) setting und...
Under the ASC payment system, Medicare will make facility payments to ASCs only for the specific ASC covered surgical pr... (more)

[EHR Incentive Program]  Will the Centers for Medicare & Medicaid Services (CMS) conduct audits as...
Any provider attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program ... (more)

[EHR Incentive Programs]  When meeting the meaningful use measure for computerized provider order entr...
If a staff member of the eligible provider is appropriately credentialed and performs similar assistive services as a... (more)

[EHR Incentive Programs] In order to receive payments under the Medicare and Medicaid Electronic Health Rec...
In order to receive Medicare EHR incentive payments, EPs, eligible hospitals,... (more)

What can I do to avoid the Physician Quality Reporting System payment adjustment?
Beginning in 2015, CMS will subject eligible professionals who are not successful reporters under Physician Quality R... (more)

How do I know if I have a PECOS Record?
There are three (3) ways to verify that you have an enrollment record in PECOS:  Check the Ordering and Referrin... (more)

If a payer/pharmacy requires a diagnosis code for a prescription and the prescriber reports an ICD-9 diagno...
When conducting a standard transaction, medical data code sets (ICD-9 and ICD-10) that are valid at the time that the se... (more)

Using Condition code 44, how should the hospital report observation services when the patient's status is c...
The use of Condition Code 44 pertains to the entire patient encounter (from the beginning of the inpatient/outpatient en... (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 identifiers used by either states or the federal government to identify service providers... (more)

[EHR Incentive Programs]  How can a provider meet the “Protect Electronic Health Information” core...
To meet the “Protect Electronic Health Information” core objective for Stage 1, eligible professionals (EP), elig... (more)

How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit ...
Since each line of a claim is adjudicated separately against the Medically Unlikely Edit (MUE) value for the code on tha... (more)

How do I report for the 2014 Physician Quality Reporting System (PQRS) if there are fewer than 9 applicable...
For 2014 PQRS eCQMs, the expectation is that eligible professionals (EPs) or group practices reporting via the Group ... (more)

Are Part B drug charges subjected to the payment adjustment for Physician Quality Reporting System (PQRS), ...
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Could you clarify CMS’ policy about the homebound status of home health patients who can drive?
The Benefit Policy Manual (Internet-Only Manual 100-02, Chapter 7, Section 30.1.1) explains in detail what it means to b... (more)

[EHR Incentive Programs]  Does the inclusion of certified Medical Assistant in the list of professiona...
We have revised the description of who can enter orders into the EHR and have it count as CPOE and have it count for pur... (more)

How are claims adjudicated with Medically Unlikely Edits (MUEs)?
For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, all CMS claims processing contractors adju... (more)

How are the measure numerator and denominator determined for the Physician Quality Reporting System (Physic...
Physician Quality Reporting measures consist of two major components. Each component is defined by specific codes descri... (more)

If an applicable manufacturer gave a contribution to support a medical conference, but did not have any say...
Unrestricted donations to a medical conference as described in this FAQ would not be subject to reporting under Open ... (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 ... (more)

[EHR Incentive Programs]  If an eligible provider fails to meet meaningful use (MU) during a participa...
An Eligible Professional (EP), Eligible Hospital or Critical Access Hospital (CAH) that participates in the Medicare ... (more)

When a hospice patient goes to a hospital for care for the terminal illness or related conditions without t...
For the duration of an election of hospice care, an individual waives all rights to Medicare payments for any Medicare s... (more)

How do I find information on a specific CMS policy or regulation?
... (more)

[EHR Incentive Programs] Is the physician the only person who can enter information in the electronic healt...
No. The Final Rule for the Medicare and Medicaid EHR incentive programs, specifi... (more)

How should modifier -59 be reported under the National Correct Coding Initiative (NCCI)?
Modifier -59 is used to indicate a "distinct procedural service". Modifier 59 may not be appended to the evaluation and ... (more)

Can a claim contain both ICD-9-CM and ICD-10-CM/PCS codes?
                   ... (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 a... (more)

Can you bill for other preventive services along with the Initial Preventive Physical Examination (IPPE) or...
The Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV) do not include other preventative... (more)

[EHR Incentive Programs]  When reporting on the Summary of Care objective in the Electronic Health Rec...
                &nbs... (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 contains a column 2 (pre... (more)

What are the mutually exclusive edits?
The mutually exclusive edits,  which were formerly contained in a separate table but are now contained in the colum... (more)

What simple steps can I take to submit Physician Quality Reporting System (PQRI) quality measures data on c...
Take the following steps to begin claims-based reporting for Physician Quality Reporting: 1). Use the measure specificat... (more)