FAQs Updated

1.     Are physicians who practice in hospital-based ambulatory clinics eligible to receive Medicare or Medicaid electronic health record (EHR) incentive payments?

Ans: A hospital-based eligible professional (EP) is defined as an EP who furnishes 90 percent or more of his/her services in either the inpatient or emergency department of a hospital. Hospital-based EPs do not qualify for Medicare or Medicaid EHR incentive payments.

If you are a new EP and need to determine your hospital-based status, contact the EHR information center at (888)734-6433 and choose option 4 in the interactive voice response system (IVR). You will need your National Provider Identifier (NPI) and the last 5 digits of your Tax Identification Number (TIN). If you are an existing EP, review and resubmit your registration on the Registration & Attestation website to determine your hospital based status.

2. What steps do eligible hospitals need to take to meet the specialized registry objective? Is it different from EPs?

Ans: For an eligible hospital, the process is the same as for an EP. However, we note that eligible hospitals do not need to explore every specialty society with which their hospital-based specialists may be affiliated.  The hospital may simply check with the jurisdiction and any such organization with which it is an affiliate, if no such organization exists, and if their jurisdiction has no registry, they may simply exclude from the measure.

3. Are Healthcare Common Procedure Coding System (HCPCS) codes Q2035 and Q2039 payable by Medicare?

Ans: Effective for claims with dates of service on or after October 1, 2010, Q2035 and Q2039 are payable by Medicare. However, the codes will not be recognized by the Medicare claims processing systems until January 1, 2011. Since no national payment limits are available for Q2035 or Q2039, payment limits will be determined by the local claims processing contractor. 

4. Which site of service code should be reported when a hospice patient resides in a hospice facility and is receiving the routine home care (RHC) or continuous home care (CHC) level of care?

Ans: When recording the site of service for a hospice patient who is receiving RHC and residing in a hospice inpatient facility, please code the location as Q5006. When recording the site of service for a hospice patient who is receiving RHC or CHC and residing in a hospice residential facility, please code the location as Q5009. This instruction may change in the future as we are considering adding a new site of service code for hospice home care provided in hospice facilities. 

5. What is a Medically Unlikely Edit?

Ans: An MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. MUEs are adjudicated either as claim line edits or date of service edits. The MUE program provides a method to report medically reasonable and necessary UOS in excess of an MUE for MUEs that are adjudicated as claim line edits. If an MUE is adjudicated as a claim line edit or a date of service edit, UOS in excess of the MUE value may be paid during the appeal process. 

6. What modifiers are allowed with the National Correct Coding Initiative (NCCI) edits?

Ans: The following modifiers are allowed with the National Correct Coding Initiative (NCCI) edits:

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC

Global surgery modifiers: 25, 58, 78, 79

Other modifiers: 27, 59, 91

Refer to Chapter I of the National Correct Coding Initiative Policy Manual for Medicare Services for changes in this list of NCCI-associated modifiers.

7. How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value?

Ans: For MUEs that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. The appropriate use of HCPCS/Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service. For MUEs that are adjudicated as date of service edits, units of service (UOS) in excess of the MUE value may be paid during the appeal process. 

8. What is the column 1/column 2 correct coding edit table?

Ans: The column 1/column 2 correct coding edit table contains two types of code pair edits. One type contains a column 2 (previously called component) code which is an integral part of the column 1 (previously called comprehensive) code. The other type contains code pairs that should not be reported together where one code is assigned as the column 1 code and the other code is assigned as the column 2 code. If two codes of a code pair edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending a National Correct Coding Initiative-associated modifier to the column 2 code of a code pair edit, payment of both codes may be allowed if the modifier indicator is "1". 

9. May an Advanced Beneficiary Notice (ABN) be utilized to bill the beneficiary for services denied due to a Medically Unlikely Edit (MUE)?

Ans: No, a provider/supplier may not issue an Advanced Beneficiary Notice (ABN) for units of service in excess of an Medically Unlikely Edit (MUE). Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability and bill the beneficiary for the denied services. It is a provider/supplier liability.

10. How do I request a change in the Medically Unlikely Edit (MUE) value for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code?

Ans: If a provider/supplier, healthcare organization, or other interested party believes that an Medically Unlikely Edit (MUE) value should be modified, it may write Correct Coding solutions, LLC at the address below. The party should include its rationale and any supporting documentation. However, it is generally recommended that the party contact the national healthcare organization whose members perform the procedure prior to writing to Correct Coding Solutions, LLC. The national healthcare organization may be able to clarify the reporting of the code in question. If the national healthcare organization agrees that the MUE value should be modified, its support and assistance may be helpful in requesting the modification of an MUE value.

Requests for modification of an MUE value should be sent to the following:

National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
FAX: 317-571-1745

11. How often are the National Correct Coding Initiative (NCCI) edits updated?

Ans: The National Correct Coding Initiative (NCCI) edits are usually updated on a quarterly basis. Note that the NCCI edits are included in the Outpatient Code Editor (OCE). Under the hospital Outpatient Prospective Payment System (OPPS), the NCCI edits are no longer one version behind. 

12. Has CMS published the Medically Unlikely Edit (MUE) values for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes?

Ans: CMS publishes on its website most Medically Unlikely Edit (MUE) values. However, CMS does not publish MUE values for some codes. The MUE values for this latter group of codes are confidential information that should not be published by third parties who have acquired them.

MUE values are not utilization guidelines. Providers may be subject to a review of their claims by claims processing contractors, program safeguard contractors (PSCs), or recovery audit contractors (RACs) even if they report units of service less than or equal to the MUE value for a Healthcare Common Procedure Coding System (HCPCS) code.

13. Is there an appeal process for claim lines denied based on Medically Unlikely Edits (MUEs)?

Ans: Since claim lines are denied at Carriers and Part A/Part B Medicare Administrative Contractors (A/B MACs) processing claims with the MCS system and at Durable Medical Equipment Medicare Administrative Contractors (DME MACs) processing claims with the VMS system, Medically Unlikely Edits (MUE)-based claim line denials at these contractors may be appealed.

However, at Fiscal Intermediaries (FIs) and A/B MACs processing claims with the Fiscal Intermediary Shared System (FISS), claims with a claim line with units of service exceeding an MUE value are returned to the provider. No claim denial occurs, and appeals are not available.

Appeals should be submitted to local contractors not the MUE contractor, Correct Coding Solutions, LLC.

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

Ans: Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. 

For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. 

Beginning in 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf). You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation. 

15. Will my payment under ICD-10 be the same as the payment I currently receive under ICD-9?

Hospitals - A fiscal year 2015 study conducted on the impact of converting Medicare Severity Diagnosis Related Groups (MS-DRGs) to ICD-10 found that moving from an ICD-9-CM-based system to an ICD-10 MS-DRG replicated system resulted in a statistically zero impact on payment. Ninety-nine percent of the records did not shift to another MS-DRG when using an ICD-10 MS-DRG system. For the 1 percent of records that shifted, 41 percent were to a higher weighted MS-DRG and 66 percent were to a lower weighted MS-DRG. The net impact across all MS-DRGs was a reduction by 4/10000 or minus 4 cents per $100, which is statistically zero impact. For more information about this study, refer to Converting MS-DRGs to ICD-10-CM and ICD-10-PCS Updated 03/03/15 With New 2015 Impact Article located in the Downloads section at :http://http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html on the CMS website.

Professional and supplier claims - Payment is based on the Healthcare Common Procedure Coding System (HCPCS) code and under ICD-10-CM, payment will also be based on the HCPCS code. A claim could be denied if the diagnosis does not warrant payment for the procedure. You should consult the appropriate payment policy, National Coverage Determination (NCD), or Local Coverage Determination (LCD) pertaining to the service you wish to bill to determine whether there are any changes to diagnosis code reporting requirements. You should also consult the 2015 payment rules and the forthcoming 2016 payment rules for ICD-10-CM impacts.

16. What procedures and services are payable when performed in the Ambulatory Surgical Center (ASC) setting under the revised ASC payment system?

Ans: Under the ASC payment system, Medicare will make facility payments to ASCs only for the specific ASC covered surgical procedures on the ASC list of covered surgical procedures published in Addendum AA of the hospital outpatient prospective payment system (OPPS)/ASC final rule for the relevant payment year. Addendum AA to the calendar year (CY) 2008 OPPS/ASC final rule is available at http://www.cms.hhs.gov/ASCPayment/ASCRN/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1213395&intNumPerPage=10. In addition, Medicare will make separate payment to ASCs for certain covered ancillary services that are provided integral to a covered ASC surgical procedure. Covered ancillary services include the following: 

• Brachytherapy sources; 
• Certain implantable items with pass-through status under the OPPS; 
• Certain items and services that CMS designates as contractor-priced, including, but not limited to, the procurement of corneal tissue; 
• Certain drugs and biologicals for which separate payment is allowed under the OPPS; and 
• Certain radiology services for which separate payment is allowed under the OPPS. 

Other non-ASC services such as physician services and prosthetic devices may be covered and separately billed under Medicare Part B. See the Medicare Claims Processing Manual, Chapter 14, Section 10.2 for more information.

17. If patients have recurring appointments for physical therapy, occupational therapy, or speech-language pathology services that will continue after ICD-10 implementation, will new orders with ICD-10 codes be required?

Ans: In cases where physician or qualified non-physician practitioner orders are applicable to rehabilitation services furnished under CMS programs, CMS is not requiring updated orders to continue rehabilitation services after ICD-10 implementation on October 1, 2015; however, these claims must contain a valid ICD-10 diagnosis code. Physicians will need to provide the appropriate ICD-10 code to the therapist for these claims. Orders created after the transition to ICD-10 must use ICD-10 codes.