Frequently Asked Questions

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Top Questions

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)

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

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)

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)

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 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)

What is the difference between a legacy provider identifier (LPI) and a National Provider Identifier (NPI)?...
LPIs are any of a kn... (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 controlled or dangerou... (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 can count as a specialized registry?
A submission to a specialized registry m... (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 transactions to indicate h... (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)

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

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)

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)

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)

What is a Qualified Clinical Data Registry (QCDR) in the 2016 Physician Quality Reporting System (PQRS)?
A qualified clini... (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)

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

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)

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)

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 individuals (persons). Thes... (more)

Which patients should be included in the denominators calculated under the Observation Services Method and ...
For the Observation Services method denominator includes patients admitted to the inpatient department (Place of Service... (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)

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 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 a... (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)

When I try to login, I get the error message stating, "Your account has been locked. Please try again later...
After three unsuccessful attempts to ... (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 differenti... (more)

What are the supervision requirements for diagnostic psychological and neuropsychological tests?
Under the diagnostic test provision as a... (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's the difference between the Outpatient Code Editor (OCE) edits and the National Correct Coding Initia...
The Outpatient Code Editor (OCE) is utilized to edit outpatient prospective payment system hospital ... (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)

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... (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)