How should modifier -59 be reported under the CCI?

QUESTION: How should modifier -59 be reported under the CCI?

ANSWER: Modifier -59 is used to indicate a distinct procedural service. To appropriately report this modifier, append modifier -59 to the column 2 code to indicate that the procedure or service was independent from other services performed on the same day. The addition of this modifier indicates to the carriers or fiscal intermediaries that the procedure or service represents a distinct procedure or service from others billed on the same date of service. In other words, this may represent a different session, different anatomical site or organ system, separate incision/excision, different lesion, or different injury or area of injury (in extensive injuries). When used with a CCI edit, modifier -59 indicates that the procedures are different surgeries when performed at different operative areas or at different patient encounters.

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Will a health care provider’s National Provider Identifier (NPI) ever change?

QUESTION: Will a health care provider’s National Provider Identifier (NPI) ever change?

ANSWER: The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process. There are some situations, however, in which an NPI may change such as when health care provider organizations determine they may need a new NPI due to, for example, certain changes of ownership, the conditions of a purchase, or a new owner’s subpart strategies. There also may be situations where a new NPI is necessary because the current NPI was used for fraudulent purposes.

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Must providers who submit claims electronically comply with HIPAA if they submit claims on paper?

QUESTION: If a provider submits claims electronically, must he or she also comply with HIPAA if the practice reverts to submitting claims on paper?
ANSWER: The HIPAA transactions commonly used by providers include claims, eligibility queries, claim status queries, and referrals. It is important to note that a provider cannot avoid the HIPAA requirements by hiring another entity, such as a billing service, to conduct these transactions electronically on the provider's behalf. While you and other health care providers could revert to conducting solely paper transactions, doing so would have many negative effects for most providers. The provider’s business processes would be disrupted by having to prepare paper claims and check eligibility and claim status by phone. Reverting to paper would cause particular problems for those providers who receive Medicare payments. First, these providers would experience delays in receiving payments, because Medicare by law cannot pay paper claims until 28 days after receipt (as opposed to 14 days for electronic claims). Second, effective October 16, 2003, Medicare was prohibited by law from paying paper claims except for those from small providers and under certain other limited circumstances. After that date, any provider that does not meet the “small provider” or other exception would have to return to electronic claims submission in order to continue to receive Medicare reimbursement. At that time, the provider would again be required to comply with the Privacy Rule requirements.

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National Provider Identifier (NPI)?

QUESTION: Under what circumstances will a claim be rejected when using the National Provider Identifier (NPI)?

ANSWER: Claims will be rejected if:
• The NPI included in a claim or claim status request does not meet the content criteria requirements for a valid NPI (begins with 1,2,3, or 4; 10-digits long with no special characters; check digit is correct); this affects:o X12 837 and Direct Data Entry (DDE) screen claims (DDE claims are submitted to Medicare Intermediaries only);o National Council of Prescription Drug Plan (NCPDP) claims (submitted to Medicare DMERCs only);o Paper claims on the revised CMS-1500 form and on the UB-04 form;o Claims submitted using Medicare’s free billing software;o Electronic claim status request received via X12 276 or DDE screen; ando Non-X12 electronic claim status queries, pending elimination of the HIPAA contingency plan for the HIPAA 276/277 format;
• A submitted NPI reported cannot be located in Medicare files;
• The NPI is located, but a legacy identifier reported for the same provider in the transaction does not match the legacy identifier in the Medicare file for that NPI;
• Claims include the NPI but do not have a taxpayer identification number (TIN) reported for the billing or pay-to provider in electronic claims received via X12 837, DDE screen (FISS only), or Medicare’s free billing software; and
• Claims that do not meet Medicare submission requirements, HIPAA implementation guide requirements, or Medicare program reuirements for reasons unrelated to NPIs.


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What is the purpose of the HIPAA Security Standards rule and why are security standards needed?

QUESTION: What is the purpose of the HIPAA Security Standards rule and why were security standards needed as published in the Federal Register on February 20, 2003?

ANSWER: The purpose of the Security Rule is to ensure that every covered entity has implemented safeguards to protect the confidentiality, integrity, and availability of electronic protected health information. Standard for security are needed because there is a growth in the exchange of protected health information between covered entities as well as non-covered entities. HIPAA mandated security standards protect an individual's health information, while permitting the appropriate access and use of that information by health care providers, clearinghouses, and health plans.

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Can ICD-9-CM procedure codes be reported on hospital outpatient claims?

QUESTION: Can ICD-9-CM procedure codes be reported on hospital outpatient claims? If I use HCPCS codes to report hospital outpatient services at the “required” service line level segment for a claim, may I use the ICD-9-CM procedure codes to report hospital outpatient services at the claim level “situational” segment?

ANSWER: NO. ICD-9-CM procedure codes were named as the HIPAA standard code set for inpatient hospital procedures. The ICD-9-CM procedure codes were not named a HIPAA standard for procedures in other settings such as hospital outpatient services or other types of ambulatory services. Hospitals may capture the ICD-9-CM procedure codes for internally tracking or monitoring hospital outpatient services; but when conducting standard transactions, hospitals must use HCPCS codes to report outpatient services at the service line level and the claim level, if the situation applies. Even though an ICD-9-CM procedure code qualifier is available, in addition to a HCPCS code qualifier, at the “situational” claim level segment, the Transactions and Code Sets regulation states that ICD-9-CM procedure codes is the adopted standard code set for hospital inpatient services

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Correct Coding Initiative (CCI) in the Medicare manuals

QUESTION: Where can I find information about the Correct Coding Initiative (CCI) in the Medicare manuals?
ANSWER: Information about CCI can be found in Section 20.9 of Chapter 23 of the Medicare Claims Manual .


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