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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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Resolved Fiscal Intermediary Standard System Claims Processing Issues

Updated: 04.01.24

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
11.30.2023	Closed	Hospice	RESOLVED: Hospice NOEs and claims submitted electronically on 11.28.2023 did not make it to FISS.	N/A	N/A	12.12.2023
MAC Action	CGS reported the issue and will provide updates when available.
Provider Action	No provider action is required.
Proposed Resolution	12.12.2023 – The files were uploaded and are available in FISS/DDE. A resolution is pending further research.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
10.16.2023	Closed	Home Health & Hospice	RESOLVED: FISS is aware some claims suspended to status/location (S/LOC) S MCABL without a reason code assigned.	N/A	N/A	10.30.2023
MAC Action	CGS will provide updates when available.
Provider Action	No provider action is required.
Proposed Resolution	10.20.2023: The VDC installed a system update that allowed claims to continue processing. A resolution is pending further research.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
08.08.2023	Closed	Home Health & Hospice	RESOLVED: Claims may return to the provider (RTP) with reason code 32103 due to an NPI Crosswalk issue. This occurs after a PECOS application under a current, active enrollment record finalizes and an incorrect historical termination date applies in FISS.	32103	N/A	11.03.2023
MAC Action	CGS will provide updates when available.
Provider Action	Continue to submit NOAs (TOB 32A) to meet the timely filing requirement. Don't submit claims or correct/resubmit any NOAs/claims that RTP until the issue is resolved.
Proposed Resolution	Update: CGS applied a manual workaround for providers who reported the issue. A global system resolution was implemented on 11.03.2023. A resolution is pending further research.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
08.02.2023	Closed	HH TOB 34X	RESOLVED: Home Health claims returned to provider (RTP’d) with reason code W7072 in error	W7072	Claims submitted between January 1 – June 30, 2023 Revenue codes 042X, 043X, 044X CPT codes 98980 and/or 98981	07.03.2023
MAC Action
Provider Action	F9/resubmit claims that RTP’d in error.
Proposed Resolution	A system update was implemented with the July 2023 quarterly release.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
08.01.2023	Closed	Home Health	RESOLVED: Some home health claims returned to provider (RTP'd) with reason code 19963 in error because the corresponding NOA is offline.	19963	NOA in Status/Location (S/LOC) O B9997	10.24.2023
MAC Action	10.06.2023 – CGS will restore the affected NOAs and process the associated claims within 45 calendar days. 08.23.2023 – A system update will not allow additional NOAs to move offline.
Provider Action	Review claims that RTP with RC 19963. If a claim doesn't meet the criteria above, correct and resubmit it.
Proposed Resolution	See MAC Action and Provider Action.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
03.29.2023	Closed	Hospice	RESOLVED: Service Intensity Add-On (SIA) Payments Not Applying to Previous Month			04.20.2023
Updates	A service intensity add-on (SIA) payment will be made for in person social worker visits and nursing visits provided by a registered nurse (RN), when provided during routine home care in the last seven days of life. When a patient is discharged deceased on a claim within the first six days of a month, CMS' system is to perform a look back on the prior month's claim to identify if there were SIA eligible services provided within the last seven days of life and if there are, a system-initiated adjustment would occur. The look back is currently not occurring. More information on SIA payments and how they applied to claims may be found in section 30.2.2 – Service Intensity Add-on (SIA) Payments, of the Medicare Claims Processing Manual.
MAC Action	This issue has been identified and is currently in research.
Provider Action	Adjust the prior month’s claim to receive any applicable SIA payment.
Proposed Resolution	The maintainers are researching.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.24.2023	Closed	Home Health	RESOLVED: Some home health (329) claims with condition code 47 received reason code U538F.	U538F	Condition Code 47	N/A
MAC Action
Provider Action	If two home health agencies (HHAs) submit an NOA for the same 30-day period, the earlier admission is truncated to the date of the second admission. Claims will return to provider (RTP) with reason code U538F when the HHA that opened the earlier admission submits a claim with a "through" date that overlaps the second HHA's admission date. Review the dates of service reported on the claim for keying errors and the beneficiary's eligibility file for overlapping home health admissions. If applicable, correct the dates of service and F9/resubmit the claim. If another HHA admission overlaps your dates of service, please contact the HHA for resolution.
Proposed Resolution	The maintainers are researching.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
08.02.2022	Closed	Home Health	RESOLVED: Home Health claims submitted with condition code DR (disaster related) during the COVID-19 public health emergency that are not matched to a corresponding OASIS assessment in iQIES cannot finalize	N/A	Condition Code DR	05.11.2023
MAC Action	CGS will remove condition code DR from affected claims to allow them to return to provider (RTP) with reason code 37253 correctly and include the following message in the Remarks field on claim page 07: DR condition code not needed. Removed so provider can submit matching OASIS.
Provider Action	Condition Code DR is not required since there is no waiver of OASIS reporting in place during the COVID-19 PHE. If a claim RTPs per the MAC Action section above, submit the missing OASIS assessment and resubmit the claim.
Proposed Resolution	See MAC Action and Provider Action.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
06.22.2022	Closed	Home Health	RESOLVED: Incorrect Partial Period Payment Adjustments on Claims		Patient discharge status code 06; Reason Code 37184	06.19.2023
Updates	06.19.2023 – A fix for this issue was implemented on June 17, 2023. Initial claim submissions, type of bill (TOB) 329, should no longer receive incorrect partial period payment adjustments. 04.24.2023 – This issue continues to affect initial claim submissions, type of bill (TOB) 329. However, provider submitted adjustment claims, TOB 327, have been successful in issuing full period payments, if applicable. 10.06.2022 – A system fix will be implemented on April 3, 2023. Please reference MM12924 for additional information.
MAC Action
Provider Action	Providers should continue to follow the April 24, 2023, Provider Action instructions in this article to receive full period payments, if applicable. Providers may submit adjustments (TOB 327) for claims that received incorrect partial period payment adjustments. Before submitting an adjustment, please ensure the partial period payment was incorrect by reviewing the reasons a partial payment would occur in the "Issue Description" section of this article below. Providers will have to update the patient status codes on the adjustments, as this issue changed the original code to 06, causing the partial period payment. The adjustments should include condition code D9 and remarks "INCORRECT PARTIAL PERIOD PAYMENT ADJUSTMENTS". CGS will bypass timely filing for claims past timely filing affected by this issue.
Proposed Resolution	Some home health claims are receiving incorrect partial period payment adjustments when the below situations are not present. Partial period payment adjustments should only occur as a result of the following situations: When a patient has been discharged and readmitted to home care within the same 30-day period of care; or When a patient transfers to another HHA during a 30-day period of care, or In cases where the patient elects Medicare Advantage (MA) coverage during an HH PPS period of care. These situations are indicated on the claim by reporting a Patient Discharge Status code of 06. Based on the presence of this code, the Pricer calculates a partial period payment adjustment to the claim.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
04.06.2023	Closed	Hospice	RESOLVED: Hospice claims being returned with Reason Code 34963	34963	NA	05.02.2023
Updates	As of 4/3/2023, we have identified hospice claims being returned to the provider (RTP) with reason code 34963. Reason code 34963 indicates the attending physician on the claim is invalid or not present in the PECOS Enrolled Physicians file, or the attending physician NPI is present on the PECOS Enrolled Physicians File, but the first four digits of the last name do not match, or the claim has a Through Date of service equal or greater than the Termination Date on the PECOS Enrolled Physician Inquiry screen. Currently, CMS does not require hospices to ensure physicians are enrolled in PECOS. As such, we are researching this issue and awaiting additional clarification from CMS. Update 4/7/2023: Within ten business days of this notification, reason code 34963 will be bypassed for hospice claims and the A/B Medicare Administrative Contractors (MACs) will return all hospice claims to processing that were returned for reason code 34963. The April 7, 2023, actions are completed. Reason code 34963 is bypassed for hospice claims and the claims that edited for reason code 34963 were returned to processing.
MAC Action	Within ten business days of this notification, reason code 34963 will be bypassed for hospice claims and the A/B Medicare Administrative Contractors (MACs) will return all hospice claims to processing that were returned for reason code 34963.
Provider Action	No provider action is required
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.02.2023	Closed	Home Health	RESOLVED: Reason Codes U5210 and U5220, Medicare Entitlement Rejections for Home Health Notice of Admissions and Claims	U5210 and U5220	NA	03.06.2023
Updates	The fix to this issue was implemented on 3/6/2023. Some home health NOAs and claims are being incorrectly rejected for Reason Code U5210 and U5220, no Medicare entitlement for the dates of service when the beneficiary only has Part B eligibility for the dates of services submitted. Medicare's entitlement to Medicare coverage for home health services only requires a beneficiary to have Part A or Part B, not both. If a beneficiary is enrolled only in Part A and qualifies for the Medicare home health benefit, then all of the home health services are financed under Part A. If a beneficiary is enrolled only in Part B and qualifies for the Medicare home health benefit, then all of the home health services are financed under Part B.
MAC Action	This issue has been identified and a fix is in development. Once an implementation date for the fix is scheduled, we will provide an update and provider direction.
Provider Action	Providers may submit NOAs and claims that were incorrectly rejected for this issue. If an NOA is late due to this issue, providers must request a late NOA exception on the corresponding claim(s) by appending modifier KX to the HIPPS code on the 0023 revenue line and indicate the following in the Remarks field of the claim(s) "NOA LATE DUE TO U5210/U5220 ISSUE."
Proposed Resolution	See above

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
08.11.2022	Closed	Home Health & Hospice	A system issue caused claims for certain beneficiaries to not process.	NA	NA	08.22.2022
Updates	08.22.2022 – This issue is resolved and CGS will release the suspended claims for processing.
MAC Action	CGS will suspend affected claims to status/location SMHICN until the issue is resolved.
Provider Action
Proposed Resolution	A resolution is in progress.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
06.02.2022	Closed	Home Health	Claims are receiving reason code 37128 in error.	37128	NA	06.08.2022
Updates	06.08.2022 – A system fix was implemented and suspended claims were released for processing.
MAC Action	Claims will suspend to status/location SM0100 until the issue is resolved.
Provider Action	No provider action is needed.
Proposed Resolution	FISS is researching.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
06.02.2022	Closed	Home Health & Hospice	Claims entered in the Direct Data Entry (DDE) system returned to the provider (RTP'd) with reason code 31300.	31300	TOBs 81A, 82A, 32A	05.16.2022
Updates	05.16.2022 – A system fix was installed. Providers may F9/resubmit claims.
MAC Action
Provider Action	A system change installed with the April 2022 quarterly release caused payer code Z to no longer auto-populate on DDE claim page 3 during claim entry. You may choose one of the following options: Access the RTP claim in the Claims Correction screen, add payer code Z and F9 the claim. Wait until the system fix is installed and F9/resubmit the claim.
Proposed Resolution	A system fix is scheduled to be implemented on 05.16.2022.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
04.26.2022	Closed	Home Health	Certain home health claim adjustments processed with an early HIPPS code when a late HIPPS code is appropriate (the end of one period to the start of the next period is 60 days or less).	NA	TOB 32G, Period end to start of next period = 60 days or less, HIPPS code 1XXXX or 2XXXX (early)	08.02.2022
Updates	08.02.2022 – A system fix was installed and CGS will adjust any remaining claims that processed in error.
MAC Action	The issue was reported and is in research.
Provider Action	You may adjust claims that processed with an incorrect HIPPS code.
Proposed Resolution	A system fix was implemented on 06.06.2022. Claim adjustments (TOB 32G) will process with the correct HIPPS code. A resolution for affected claims is still pending or see Provider Action.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
03.25.2022	Closed	Multiple	Cancel claims with a 2022 date of service rejected and posted to the Common Working File (CWF) in error.	C7113, C7115, C7120, U5600, U5366, etc.	TOB XX8	08.22.2022
Updates	08.22.2022 – This issue is fully resolved. Cancel claims that posted to the CWF between 01.01.2022 and 03.21.2022 in error are no longer present on the CWF.
MAC Action
Provider Action	08.22.2022 – You may resubmit claims that edited against a cancel claim that posted to CWF in error.
Proposed Resolution	03.21.2022 – A system fix was implemented. Cancel claims submitted after this date will not post to CWF. A resolution for claims that posted to CWF prior to this date is still pending.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.15.2022	Closed	Home Health	Home Health Notices of Admission (HH NOAs) with an admission date that falls within a hospice period are rejecting with reason code U5235 in error.	U5235	TOB 32A	02.28.2022
Updates	02.28.2022 – A system fix was implemented. Please see Provider Action below.
MAC Action
Provider Action	F9/resubmit NOAs that received reason code U5235 in error. If an NOA is late due to this issue, you may request a late NOA exception. After the NOA processes, submit the final claim (TOB 329) with modifier KX on the revenue code 0023 line and "2022 NOA REASON CODE U5235 ISSUE" in the Remarks field.
Proposed Resolution	02.21.2022 – A system fix will be implemented at a future date.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
01.19.2022	Closed	Home Health	Some Home Health Notices of Admission (HH NOAs) returned to the provider (RTP'd) with reason code U537F in error.	U537F	TOB 32A	06.20.2022
Updates	06.20.2022 – A system fix was implemented on 6.20.2022. Please reference the most recent Provider Action update below. 05.16.2022 – A system fix was implemented on 05.16.2022. Please reference the most recent Provider Action update below. 05.02.2022 – A system fix was implemented on 04.25.2022. Please reference the most recent Provider Action update below. 04.14.2022 – A system fix was implemented with the April quarterly release on 04.04.2022, but the issue was not fully resolved. 03.18.2022 – Please reference Provider Action update below.
MAC Action	01.19.2022 – CGS is working with CMS to correct the issue.
Provider Action	05.16.2022 – F9/resubmit NOAs that received Reason Code U537F in error. If an NOA is late due to this issue, you may request a late NOA exception. After the NOA processes, submit the final claim (TOB 329) with modifier KX on the revenue code 0023 line and "2022 NOA REASON CODE U537F ISSUE" in the Remarks field. 05.02.2022 – Determine the appropriate scenario/solution below: Reason Code U537F will assign when the NOA is a duplicate. Ensure the original NOA processes. No action is needed for the duplicate NOA. Reason Code U537F will assign when there is an open admission period on file (patient status 30) from a different home health agency in 2022 or later. If the patient was discharged from another facility, but the discharge claim has not been submitted/processed, F9/resubmit the NOA with condition code 47. If Reason Code U537F assigned for a reason other than the above, F9/resubmit the NOA with condition code 47, if applicable. If an NOA is late due to this issue, you may request a late NOA exception. Once the NOA processes, submit the final claim with modifier KX on the revenue code 0023 line and "2022 NOA REASON CODE U537F ISSUE" in the Remarks field. 03.18.2022 – Determine if the edit is appropriate. Reason Code U537F should assign when: Duplicate NOAs are submitted for the same admission period. Ensure the original NOA processes. No provider action is needed for the duplicate NOA that returned with U537F. There is an open admission period on file (patient status 30) from a different home health agency in 2022 or later. Submit the NOA with condition code 47 if the patient was discharged from another facility, but the discharge claim has not been submitted/processed. To avoid this edit, verify prior billing before you submit a new NOA for a beneficiary admission. Reason Code U537F is assigning in error when: The Common Working File (CWF) does not correctly recognize a discharge (patient status other than 30 on the last HH period). The NOA edits against a period opened prior to CY 2022. There is currently no workaround and a system fix is pending. If an NOA is late due to this issue, request a late NOA exception and indicate "2022 NOA issue RC U537F" in the Remarks field of the final claim. 01.19.2022 – Verify prior billing before you submit a new NOA for a beneficiary admission. Reason Code U537F assigns when: The Common Working File (CWF) does not correctly recognize a discharge (patient status other than 30 on the last HH period). There is currently no workaround and no provider action is needed. Multiple NOAs are submitted for the same admission period. Ensure a pending/not finalized (suspended) NOA does not exist before you submit a new NOA for a beneficiary admission. The provider number on the incoming admission period does not match the provider number on the prior HH episode posted at CWF. Submit the NOA with Condition Code 47 (only if the patient was transferred/discharged from another HHA).
Proposed Resolution	03.18.2022 – A system fix is pending.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
09.01.2021	Closed	Home Health	Claims with a HIPPS code indicating a community admission are cycling when the Common Working File (CWF) finds an applicable post-acute stay in an inpatient rehabilitation unit or a psychiatric unit of a Critical Access Hospital (CAH).	C727D	NA	04.04.2022
Updates	04.04.2022 – This issue was resolved with the implementation of the April 2022 quarterly release. Suspended claims were released for processing. 11.23.2021 – Claims are now being held in status/location SMSR02.
MAC Action	09.01.2021 – Claims will suspend to status/location SMHIP2 until the April 2022 quarterly release is implemented.
Provider Action	09.01.2021 – No provider action is needed.
Proposed Resolution	09.01.2021 – This issue will be resolved when the April 2022 quarterly release is implemented.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
08.31.2021	Closed	Home Health	Claims are receiving reason code 39910 in error when the corresponding Request for Anticipated Payment (RAP) is received 30 days or more after the claim From date.	39910	NA	04.04.2022
Updates	04.04.2022 – This issue was resolved with the implementation of the April 2022 quarterly release. Suspended claims were released for processing. 11.23.2021 – Claims are now being held in status/location SMSR01. 09.14.2021 – Claims will suspend to status/location SM0530 until the April 2022 quarterly release is installed.
MAC Action	08.31.2021 – Claims will suspend to status/location SMNREM until the April 2022 quarterly release is installed.
Provider Action	08.31.2021 – No provider action is needed.
Proposed Resolution	08.31.2021 – This issue will be resolved when the April 2022 quarterly release is installed. Since the claims will not be paid, there is no cash flow impact on providers and no interest will be paid by the Medicare program.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.17.2022	Closed	Home Health	Home Health Notices of Admission (HH NOAs) were assigned an incorrect Julian date in the DCN and returned to the provider (RTP'd) with reason code 31254 in error.	31254	TOB 32A Receipt Date 1.29.2022, 1.30.2022 or 1.31.2022 DCN 222028########XXR	02.01.2022
Updates
MAC Action
Provider Action	Submit a new NOA (TOB 32A). Report the following on the final claim (TOB 329): Modifier KX Remarks: Issue with RC 31254
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
01.03.2022	Closed	Home Health	Home Health Notices of Admission (HH NOAs) submitted via EMC are returning to the provider (RTP) in error.	32114	TOB 32A or 32D	01.14.2022
Updates	01.31.2022 – A system fix was successfully implemented on 1.14.2022.
MAC Action
Provider Action	01.05.2022 – To prevent any late NOAs, please use the following workaround: Access the NOA in the Direct Data Entry (DDE) Claims Correction screen. Enter the facility's nine-digit ZIP code in the appropriate field. F9/resubmit the claim. To avoid this edit, you may choose to submit NOAs via DDE (rather than EMC) until a system fix can be implemented. If an NOA is late due to this issue, indicate the following in the Remarks field of the final claim: Jan 2022 Issue RC 32114.
Proposed Resolution	01.05.2022 – A system fix will be implemented at a future date.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
08.31.2021	Closed	Home Health	Coinsurance or deductible should not be applied to COVID-19 vaccine and monoclonal antibodies claims with condition codes MA and 78.	WW488	HCPCS codes 0001A, 0002A, 0011A, 0012A, 0031A, M0239, M0243, M0244, M0245 and M0246	10.04.2021
Updates	10.25.2021 – This issue was resolved with the successful implementation of the October 2021 quarterly release.
MAC Action	08.31.2021 – Claims will suspend to status/location SM0488 until the October 2021 quarterly release is installed.
Provider Action	08.31.2021 – No provider action is needed.
Proposed Resolution	08.31.2021 – This issue will be resolved when the October 2021 quarterly release is installed. Claims will then be released to process.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
01.29.2021	Closed	Home Health	Some LUPA claims are being incorrectly rejected with claim reason code 39929 and line level reason code 37363 indicating the request for anticipated payment (RAP) was submitted untimely.	39929 Claim Level 37363 Line Level	Low Utilization Payment Adjustment (LUPA) claims	10.04.2021
Updates	10.25.2021 – This issue was resolved with the successful implementation of the October 2021 quarterly release. 06.10.2021 – LUPA claims that were incorrectly rejected with reason code 37363 have been reprocessed. The Claims department will continue to suspend and bypass the edit on claims with reason code 37363. This will continue until the October 2021 quarterly system release. 04.21.2021 – CMS will issue a Change Request (CR) to allow LUPA claims to process correctly when the RAP is submitted timely. This CR is scheduled for implementation in the October 2021 quarterly system release. In the interim, claims with the reason code 37363 will be suspended and the Claims department will bypass the edit on all affected claims. LUPA claims affected by this issue will be reprocessed. 03.25.2021 – No additional update at this time. 03.08.2021 – CGS is exploring a possible workaround for this issue.
MAC Action	04.21.2021 – Claims with the reason code 37363 will be suspended and the Claims department will bypass the edit on all affected claims. LUPA claims affected by this issue will be reprocessed. 02.04.2021 – Further research is being done.
Provider Action	04.21.2021 – No action is required by providers. 03.25.2021 – Update: No action is required by providers at this time.
Proposed Resolution	04.21.2021 – A CR to resolve this issue is scheduled for implementation in the October 2021 quarterly system release.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
04.30.2021	Closed	Home Health	Some 2021 home health claims are going to the return to provider (RTP) file incorrectly with reason code 37257 indicating that the Core-Based Statistical Area (CBSA) and Federal Information Processing Standards (FIPS) code combinations are invalid.	37257	CBSA/FIPS coding	07.06.2021
Updates	07.08.2021 – This issue was resolved with the implementation of the July 2021 system release. Refer to the Provider Action below. 06.11.2021 – No additional update at this time. An update will be provided when available. 04.30.2021 – This issue has been identified and a correction to the Home Health Pricer module is in development for implementation. An implementation date has not been determined. Refer to the Provider Action below.
MAC Action
Provider Action	07.08.2021 – If you have claims affected by this issue and processed with the 2020 CBSA codes, submit an adjustment and correct the CBSA code to received correct reimbursement. If you have claims in the RTP file with reason code 37257 related to this issue, press F9 to continue processing. 04.30.2021 – Until the correction to the Pricer module is implemented, home health providers may submit 2021 claims with the 2020 CBSA codes to receive reimbursement. This will likely cause an underpayment. Once the fix is implemented, HHAs will need to adjust their claims and correct the CBSA to receive correct reimbursement.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
03.08.2021	Closed	Home Health	On some claims, the submitted HIPPS code is not being replaced by the system-calculated code. As stated in the Section 4.02 of the Home Health Billing Manual, grouping to determine the HIPPS code used for final payment of the period of care will occur in Medicare systems, and the submitted HIPPS code on the claim will be replaced with the system-calculated code.	NA	HIPPS	05.2021
Updates	07.08.2021 – This issue has been resolved. If you have a claim that processed with the incorrect HIPPS code, submit an adjustment, and add "REMARKS" indicating that the claim originally paid with the incorrect HIPPS Code. The adjustment will allow the claim to go through GROUPER and apply the correct HIPPS code. If the adjustment does not process with the correct HIPPS code, please contact the Provider Contact Center at 1.877.299.4500 (option 1). 06.11.2021 – No additional update at this time. An update will be provided when available. 04.30.2021 – CMS and the software maintainers are working on an issue with the GROUPER software. At this time, if you feel that your claim processed with the incorrect HIPPS code, submit an adjustment, and add "REMARKS" indicating that the claim originally paid with the incorrect HIPPS Code. The adjustment will allow the claim to go through GROUPER and apply the correct HIPPS code. If the adjustment does not process with the correct HIPPS code, please contact the Provider Contact Center at 1.877.299.4500 (option 1). 03.25.2021 – No additional update at this time.
MAC Action	03.10.2021 – This issue has been reported and is in research.
Provider Action	04.30.2021 – Refer to the 04.30.2021 information under "Updates." 03.10.2021 – No action is required by providers at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
03.08.2021	Closed	Payment / Remittance Advice	The penalties for late Requests for Anticipated Payments (RAPs) are correctly applying on the claim for the late RAP. However, the claim's penalty amount (shown with value code QF) is not being deducted from the final reimbursement of the claim, which is causing an out of balance on the remittance advice (RA). This out of balance is showing in the "Adjustment to Balance" field on the RA Summary page.	NA	Value Code QF	04.05.2021
Updates	04.05.2021 – This issue has been resolved. CGS will generate adjustments to correct reimbursement of the affected claims. 03.25.2021 – No additional update at this time. 03.08.2021 – The system maintainer and CMS are aware of this issue.
MAC Action	04.05.2021 – CGS will generate adjustments to correct reimbursement of the affected claims.
Provider Action	04.05.2021 – No provider action required. 02.09.2021 – No provider action is necessary at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.09.2021	Closed	Home Health	Some Home Health PDGM claims that have dates of service that span 2020 - 2021 are not paying correctly. Instead of paying the 2021 Pricer rates, they are paying at the 2020 rates.	NA	Incorrect Reimbursement	04.05.2021
Updates	04.05.2021 – This issue has been resolved. CGS will generate adjustments to correct reimbursement of the affected claims. 03.25.2021 – A corrected home health Pricer program will be implemented on April 2, 2021, to correct this issue. Within 60 days after the corrected home health Pricer is installed, CGS will initiate adjustments to the affected claims. 03.08.2021 – An updated Pricer will be implemented on April 2, 2021.
MAC Action	04.05.2021 – CGS will generate adjustments to correct reimbursement of the affected claims. 03.25.2021 – Within 60 days after the corrected home health Pricer is installed, CGS will initiate adjustment to claims with a "From" date before January 1, 2021, a "Through" date on or after January 1, 2021, and a claims receipt date before April 2, 2021. 02.09.2021 – The system maintainer and CMS are aware of this issue.
Provider Action	04.05.2021 – No provider action is necessary. 03.25.2021 – No provider action is necessary. 02.09.2021 – No provider action is necessary at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.03.2021	Closed	Home Health	Some home health claims are receiving reason code C727D/C727E inappropriately indicating there is an inpatient stay within 14 days before the start of the home health period of care.	C727D/C727E	HIPPS Code	07.2021
Updates	07.08.2021 – This issue has been resolved. 06.11.2021 – No additional update at this time. An update will be provided when available. 03.25.2021 – No additional update at this time. 03.08.2021 – No additional update at this time. 02.24.2021 – This issue has been reported to the system maintainer. Claims that receive reason code C727D or C727E will suspend in status/location S MHIPP or S M727E. Our Claims department will review the claim to ensure that the HIPPS code is coded correctly. If the HIPPS code is correct, the Claims department will move the claim to continue processing. If the HIPPS code is not correct, the claim will be moved to status/location S MHIP1.
MAC Action	02.03.2021 – Further research is being done.
Provider Action	07.08.2021 – No provider action is necessary. 02.03.2021 – No provider action is necessary at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
01.20.2021	Closed	Home Health	Home Health requests for anticipated payments (RAPs) are going to the return to provider (RTP) file incorrectly with reason code W7216 indicating an invalid line item date.	W7216	RAP type of bill 322	04.05.2021
Updates	04.05.2021 – This issue has been resolved. 03.25.2021 – A resolution to this issue is anticipated in the April 2021 system release. 03.08.2021 – No additional update at this time. 02.10.2021 – RAPs that are being suspended in status/location S MWRAP, are being reviewed by the Claims department. When applicable, this reason code will be overridden to allow the RAP to continue processing. 01.22.2021 – Until this issue is resolved the reason code W7216 has been revised to suspend RAPs in status/location S MWRAP.
MAC Action	01.20.2021 – CGS Technical Support staff is currently researching this issue.
Provider Action	04.05.2021 – No provider action required. 01.20.2021 – No provider action required at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
10.02.2020	Closed	Home Health	Low Utilization Payment Adjustment (LUPA) claims are processing with incorrect early/late episodes resulting in an incorrect payment.	U524P and U524Q	Incorrect Payments	07.06.2021
Updates	07.08.2021 – This issue has been resolved with the implementation of the July 2021 system release. If you have LUPA claims that resulted in an incorrect payment due to an incorrect early/late HIPPS codes for a period of care, you may submit an adjustment. For adjustments with dates of service between January 1, 2020, and June 30, 2020, CGS will override the untimely filing edits. Please add "LUPA early/late HIPPS code issue" in the Remarks field. 06.11.2021 – No additional update at this time. An update will be provided when available. 03.25.2021 – No additional update at this time. 03.08.2021 – No additional update at this time. 01.19.2021 – No additional update at this time. As mentioned, a resolution is anticipated to be implemented in July 2021. 11.30.2020 – No additional update at this time. 10.19.2020 – A resolution to this issue is anticipated to be included in an upcoming Change Request for implementation in July 2021. 10.02.2020 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS).
MAC Action
Provider Action	07.08.2021 – If you have LUPA claims that resulted in an incorrect payment due to an incorrect early/late HIPPS codes for a period of care, you may submit an adjustment. For adjustments with dates of service between January 1, 2020, and June 30, 2020, CGS will override the untimely filing edits. Please add "LUPA early/late HIPPS code issue" in the Remarks field. 10.02.2020 – No action required
Proposed Resolution	10.02.2020 – Once this issue is resolved adjustments will likely be necessary to correct the payment.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
09.25.2020	Closed	Home Health	Low Utilization Payment Adjustment (LUPA) claims are incorrectly being sent to the Return to Provider (RTP) file because the Common Working File (CWF) believes a Request for Anticipated Payment (RAP) is needed. Reason codes affected are U5387 and U5391. Other reason codes, which begin with the letter U may also be affected.	U5387	LUPA	07.2021
Updates	07.09.2021 – This issue has been resolved. 06.11.2021 – No additional update at this time. An update will be provided when available. 03.08.2021 – No additional update at this time. 01.19.2021 – No additional update at this time. 11.30.2020 – No additional update at this time. 10.19.2020 – A resolution to this issue is anticipated to be included in an upcoming Change Request for implementation in July 2021. 10.15.2020 – Reason codes U5387 and U5391 are affected by this issue. In addition, other reason codes that begin with the letter "U" may also be affected. 09.25.2020 – This issue has been reported to the Fiscal Intermediary Standard System (FISS) maintainers, CWF, and the Centers for Medicare & Medicaid Services (CMS).
MAC Action
Provider Action	10.19.2020 – Providers should continue to submit a RAP when a LUPA claim goes to the RTP file with U5387, U5391, or other possible reason codes that begin with a U. 09.25.2020 – Until this issue is resolved, providers can submit a RAP for claims that receive the U5387 reason code.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
01.28.2021	Closed	Home Health	The HH Pricer program is incorrectly applying a penalty to RAPs received more than 5 days earlier than the "FROM" date of the RAP. The associated claims cannot be readily identified for MAC suspension.	NA	Requests for Anticipated Payments (RAPs)	03.08.2021
Updates	03.08.2021 – The system fix has been implemented. CGS is in the process of completing the adjustments. 01.28.2021 – A system fix is scheduled for March 1, 2021. Once the fix is implemented, the Medicare Administrative Contractors (MACs) shall adjust claims with a value code QF amount greater than $0 (penalty amount) and a RAP RECEIPT DT of more than 5 days earlier than the "FROM" date.
MAC Action
Provider Action	03.08.2021 – No provider action necessary. 01.28.2021 – Agencies may still submit RAPs as they choose. We will provide updates when applicable.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
07.21.2020	Closed	Hospice	Payment for hospice routine home care (RHC) services are calculating incorrectly when there is a transfer involved.	NA	RHC (high/low payment)	03.08.2021
Updates	03.08.2021 – This issue has been resolved. 01.19.2021 – No additional update at this time. 11.30.2020 – No additional update at this time. 10.28.2020 – It has been determined that the anticipated January 2021 date to implement a resolution to this issue is no longer feasible. No additional date has been provided. 10.19.2020 – No additional update at this time. 09.25.2020 – No update at this time. 07.21.2020 – The Centers for Medicare & Medicaid Services (CMS) is aware of this issue. A resolution to resolve this issue is anticipated in January 2021.
MAC Action
Provider Action	05.10.2021 – If a claim affected by this issue was processed or adjustment prior to April 19, 2021, you may need to adjust the claim again to receive the correct reimbursement. 04.22.2021 – If providers have claims that are affected by this issue, please submit an adjustment to receive the correct reimbursement.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.05.2021	Closed	Home Health	CR 11855 indicates starting 01/01/21 providers can submit both the first and 2nd RAP for a 60-day certification at the same time. Providers submit the RAP for the 2nd 30-day period with the first day of the period as the service date on the 0023 line. Because the claim's 0023 service date doesn't match the date of the first visit, the claim receives reason code U5391 indicating that it can't find a matching RAP.	U5391 or 38107	0023 Service Date	02.22.2021
Updates	02.22.2021 – When home health agencies use the new exception, which was implemented with MLN/CR 11855, and submit RAPs with the 1st day of the period of care as the service date on the 0023 line for subsequent periods of care in calendar year 2021, the corresponding claim must be submitted with the same date on the 0023 revenue code line. The service dates on the 0023 revenue code line on the RAP and the claim must match. Refer to the Reason Codes U5391 and 38107: No RAP or No Matching RAP is Found article for additional information. 02.12.2021 – This issue may also cause claims to receive reason code 38107.
MAC Action	02.09.2021 – This has been reported to the system maintainer.
Provider Action	02.09.2021 – No provider action is necessary at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.04.2021	Closed	Home Health	A zero total payment amount on LUPA claims, subject to the late 2021 RAP, penalty is causing out of balance problems on the remittance advice.	7ERTC	LUPA	02.25.2021
Updates
MAC Action	02.25.2021 – The resolution to this issue has been implemented; therefore, claims suspended in status/location S MPRTC with reason code 7ERTC have been released to continue processing. 02.04.2021 – LUPA claims with a zero total payment, subject to the late 2021 RAP penalty, will be suspended in status/location S MPRTC with reason code 7ERTC. These will be held until the Pricer is corrected during implementation on 3/1/2021.
Provider Action	02.04.2021 – No provider action is necessary at this time.
Proposed Resolution	02.25.2021 – No claims were processed prior to the suspension; therefore, no adjustments are necessary. 02.04.2021 – After the fix is implemented, CGS will adjust any claims that processed prior to the suspension to correct the payment.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
01.07.2021	Closed	Home Health	Home health requests for anticipated payment (RAPs) with dates of service on or after January 1, 2021, are going to the Return to Provider (RTP) file incorrectly when value code 61 is not present. Per MM11855, value code (VC) 61 is optional.	32035	Value Code 61 on RAPs	01.13.2021
Updates	01.13.2021 – CGS received instruction from the Centers for Medicare & Medicaid Services (CMS) to implement a workaround. Claims receiving reason code 32035 will suspend (S status code), rather than RTP. Once suspended, CGS will add value code 61 and a placeholder CBSA code 10180 to the RAP so it can continue to process.
MAC Action	01.07.2021 – CGS and CMS are aware of this issue.
Provider Action	01.13.2021 – Due to the instructions received from CMS, there is no longer a need for providers to report VC 61 and the CBSA code. No further action is required for providers. 01.07.2021 – Although VC 61 is optional for RAPs with dates of service on or after January 1, 2021, providers should continue to report VC 61 until this issue can be resolved. If you have RAPs in the RTP file, apply the VC 61 and the CBSA code to resolve reason code 32035.
Proposed Resolution	01.13.2021 – See the "Updates" information above.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
11.20.2021	Closed	Hospice	Some hospice notices of election (NOEs) are posting to the Common Working File, but then going to the Return to Provider (RTP) file with reason code U5106.	U5106	NOE	02.08.2021
Updates	02.08.2021 – This issue is caused by an abnormal system termination at the Common Working File (CWF) that happens only occasionally. Refer to Provider Action below. 11.30.2020 – No additional update at this time.
MAC Action	11.10.2020 – CGS is researching the issue.
Provider Action	02.08.2021 – When an NOE is in the RTP file with reason code U5106, and the hospice election period is posted on CWF, contact the Home Health & Hospice Provider Contact Center for assistance. 11.10.2020 – No action for providers at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
11.10.2020	Closed	Hospice	Hospice claims submitted with Occurrence Span Code (OSC) 77 are incorrectly going to the Return to Provider (RTP) file with reason code 34923.	34923	OSC 77	01.19.2021
Updates	01.19.2021 – The reason code 34923 was modified to ensure hospice claims with OSC 77 only count the units in non-covered revenue code lines with a date of service within the OSC 77 dates. 11.30.2020 – No additional update at this time.
MAC Action
Provider Action	01.19.2021 – No action for providers. 11.10.2020 – No action for providers at this time
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
04.17.2020	Closed	Hospice Health	When an 8XB NOTR is billed and the through date is past the current open benefit period on the Common Working File, the NOTR will open the next benefit period. This is working as expected. However, when the final hospice claim is submitted it is being sent to the Return To Provider (RTP) with reason code U5165.	U5165	8XB Type of Bill	04.27.2020
Updates	10.28.2020 –This issue has been resolved. Providers no longer need to follow the workaround identified in the Provider Action section below. 10.19.2020 – No additional update at this time. 09.25.2020 – No additional update at this time. 07.30.2020 – No additional update at this time. 07.10.2020 – No additional update at this time. 06.26.2020 – No additional update at this time. 06.12.2020 – No additional update at this time. 05.15.2020 – No additional update at this time. 05.05.2020 – No additional update at this time.
MAC Action	04.17.2020 – This issue is currently being researched by CWF.
Provider Action	10.28.2020 – This issue has been resolved. Providers no longer need to follow the workaround. 04.17.2020 – A workaround to this is to cancel the 8XB by billing an 8XD. Once this is completed, ensure the 42 occurrence code and discharge date are added to the final claim and F9 it out of RTP. If you haven't submitted the final claim yet, submit the 8X4 with the Occ Cd 42 and discharge date.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
07.10.2020	Closed	Home Health and Hospice	CGS has identified an issue causing some home health and hospice claims to receive reason codes 31138 and W7218 inappropriately.	31138 and W7218	NA	07.15.2020
Updates	07.15.2020 – Claims with reasons 31138 and W7218 in status/location S MOPPS have been released to continue processing. 07.10.2020 – Claims receiving these reason codes will be suspended in status/location S MOPPS.
MAC Action
Provider Action	07.15.2020 – No action by providers is necessary. 07.10.2020 – No action required.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
07.09.2020	Closed	Home Health and Hospice	Reason Code 37578 is causing claims submitted via Direct Data Entry (DDE) to go to the Return to Provider (RTP) file incorrectly.	37578	Physician National Provider Identifier (NPI)	08.17.2020
Updates	09.25.2020 – This issue has been resolved. 07.30.2020 – A resolution to this issue is scheduled for implementation on August 17, 2020. 07.09.2020 – Claims are being sent to RTP incorrectly with reason code 37578. CGS is researching the issue.
MAC Action
Provider Action	07.09.2020 – No action necessary at this time.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
07.08.2020	Closed	Home Health	Home health claims submitted as part of the Maryland Total Cost of Care Model were denied incorrectly.	32072, 37236 and 37237	Type of Bill 032X	08.11.2020
Updates	07.13.2020 – Adjustments have been completed to previously denied home health claims submitted by nurse practitioners in Maryland as part of the Maryland Total Cost of Care Model. 07.08.2020 – CGS has been instructed by CMS to reprocess the previously denied home health claims submitted by nurse practitioners in Maryland as part of the Maryland Total Cost of Care Model.
MAC Action	07.08.2020 – CGS will reprocess claims with From dates of service on or after January 1, 2020, that were received before April 27, 2020. CMS has instructed CGS to complete this process by August 11, 2020.
Provider Action	07.08.2020 – Providers may adjust the claims affected.
Proposed Resolution	07.08.2020 – Claims affected by this issue will be reprocessed by August 11, 2020.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
04.28.2020	Closed	Hospice	As a result of additional research, it has been determined that there is a continuing overpayment issue that occurs with hospice adjustments. The resolution implemented on January 20, 2020, did not correct this issue.	NA	Routine Home Care	06.12.2020
Updates	06.12.2020 – This issue has been resolved. Providers may adjust claims with routine home care days when the prior days used are greater than 60 as necessary. 05.15.2020 – No additional update at this time. 04.28.2020 – A resolution to this issue has now been scheduled for October 2020.
MAC Action
Provider Action	06.12.2020 – Provider may continue to adjust claims as necessary. 04.28.2020 – Providers are advised to hold adjustments to claims with routine home care days when the prior days used are greater than 60.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
04.17.2020	Closed	All Home Health and Hospice Providers	CGS is aware of delays in answering questions that have been submitted to the CGS.ERS.CORR@cgsadmin.com mail box. Our resources have been focused on getting payments made and we are now working through the questions that have been submitted. It may take a few days to work through all the questions but you will get a response as quickly as possible.	NA	NA	06.01.2020
Updates
MAC Action
Provider Action
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
03.12.2020	Closed	Home Health	The HIPPS code on Home Health Patient-Driven Groupings Model (PDGM) claims are being recoded incorrectly.	NA	HIPPS Code	05.18.2020
Updates	06.12.2020 – CGS has initiated the adjustments for the two issues described below. 05.15.2020 – No additional update at this time. 04.27.2020 – There were two issues involved. The first affected 60-day episode claim that spanned January 1, 2020. If the number of therapy visits changed the HIPPS code, the HH Pricer program bypasses portions of the recoding process, causing appropriate recoding of the first and fourth positions of the HIPPS code but omitted the second and third positions. Claim my have been either over or under paid depending on whether therapy services increased or decreased during the period The second recoding issue affected 30-day period of care. When a claim reported an institutional referral source using codes 61 or 62, the Grouper coded the claim into an institutional payment group correctly and assigned early or late period timing correctly. However, if the Common Working File (CWF) records indicated that the early or late was incorrect, the claim received edits 524P (early period should be late) or 524Q (late period should be early). When the claim went through Grouper the second time to correct the period timing, the occurrence code 61 or 62 was omitted, resulting in incorrect assignment of community referral source causing the claim to be underpaid. 04.06.2020 – No additional update at this time. 03.12.2020 – This issue has been reported to the system maintainer and a fix to resolve this issue is anticipated in May 2020.
MAC Action	06.12.2020 – CGS has initiated the adjustments for the two issues described below. 04.27.2020 – For the first issue, the HH Pricer was corrected on the April 2020 release. CGS will adjust the affected home health claims within 60 days. For the second issue, FISS will correct this on May 4, 2020. CGS will adjust the affected home health claims within 60 days of the May 4th date.
Provider Action	06.12.2020 – No action is required by providers. 04.27.2020 – No action is required by providers.
Proposed Resolution	03.12.2020 – A fix to resolve this issue is anticipated in May 2020.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.14.2020	Closed	Hospice	For some hospice adjustments the end of life (EOL) Service Intensity Add-On (SIA) payment is not being made. This applies to some adjustments with dates of services prior to January 1, 2020, that were received on or after January 1, 2020.	NA	NA	04.20.2020
Updates	04.27.2020 – The fix to resolve this issue has been implemented. 04.06.2020 – A fix to resolve this issue has been scheduled for April 20, 2020.
MAC Action	02.14.2020 – None at this time.
Provider Action	04.06.2020 – Provider may resubmit adjustments that were affected by this issue. 02.14.2020 – Providers should keep track of their adjustments that apply to this issue.
Proposed Resolution	02.14.2020 – A fix for this issue will be implemented. No date has been scheduled at this time.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.24.2020	Closed	Home Health	Home health claims with dates of services on or after January 1, 2020, claims are going to the return to provider (RTP) file with reason code 37253 (no OASIS found). Currently, research does not indicate that there is a systems issue. Please refer to the Provider Action below.	37253	NA
Updates
MAC Action
Provider Action	02.24.2020 – The following 4 items must match between the claim and the OASIS submitted via iQIES. Refer to the Reason Code 37253 and the OASIS Assessment article for additional information. Home health agency (HHA) Certification Number (OASIS item M0010) Beneficiary Medicare Number (OASIS item M0063) NOTE: The beneficiary's Medicare Beneficiary Identifier (MBI) may have changed; therefore, ensure the BMI matches between the claim and the OASIS. Assessment Completion Date (OASIS item M0090) Reason for Assessment (OASIS Item M0100) equal to 01, 03, or 04 It is important for providers to verify that the OASIS was successfully accepted into the iQIES database and that the above items match with the claim. If you believe the above items match between the OASIS and the claim, but you continue to encounter issues, please contact the PCC at 1.877.299.4500 (option 1) for further assistance. Please be prepared to provide screen prints of the OASIS acceptance report if requested.
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
04.10.2020	Closed	Home Health	There is an issue with the iQIES files which is causing claims to go to the Return to Provider (RTP) file with 37253 (no OASIS assessment found.) This issue is occurring with all Medicare Administrative Contractors (MACs) who processes home health claims.	37253	NA	04.13.2020
Updates	04.13.2020 – This issue has been resolved. 04.10.2020 – This issue has been reported to Medicare and the system maintainer and is being researched.
MAC Action
Provider Action	04.13.2020 – If you believe your claim went to RTP with reason code 37253 in error from April 6 through April 10, 2020, press F9 to move your claim out of RTP and continue processing
Proposed Resolution

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.24.2020	Closed	Home Health and Hospice	CGS has identified an issue affecting (XX7 type of bill) and cancellations (XX8 Type of bill) that are submitted via Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE), which are returning with reason code 30918. When entering these adjustments and cancellations thru DDE, the incorrect Medicare Beneficiary Identifier (MBI) is being applied.	30918		0302.2020
Updates	03.02.2020 – The fix that resolved this issue was implemented over the weekend. The Claims department is working to release the adjustments and cancels that were suspended in status/location S MBII1 due to this issue.
MAC Action	03.02.2020 – The Claims department is working to release the adjustments and cancels that were suspended in status/location S MBII1 due to this issue. 02.24.2020 – These claims will be suspended to SMBII1. The Claims department will work to correct the MBI.
Provider Action	02.24.2020 – Some adjustments/cancels may have been sent to your Return to Provider (RTP) file (status/location T B9997). If you have adjustments in RTP with reason code 30918, please verify that it has the correct MBI and F9. There are two options providers can choose from when entering adjustments/cancels. You may F9 each adjustment/cancel you enter, or after entering one adjustment/cancel, log out of FISS DDE and log back in to enter your next adjustment/cancel.
Proposed Resolution	02.24.2020 – A fix to this issue will be implemented and in production on Monday, March 2, 2020.

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
02.10.2020	Closed	Hospice	Physician charges on hospice claims (revenue code 0657) received by CGS between 10.07.2019 – 01.05.2020 were overpaid.	NA	Revenue Code 0657 for claims received between 10.07.2019 – 01.05.2020	02.10.2020
Updates	02.21.2020 – This issue has been resolved. Refer to the MAC Action and Provider Action below.
MAC Action	02.10.2020 – CGS will adjust claims that are brought to their attention.
Provider Action	02.10.2020 – CGS will adjust claims that are brought to their attention.
Proposed Resolution	NA

Date Reported	Status	Provider Type Impacted	Description of Issue	Reason Codes	Claim Coding Impact	Date Resolved
01.21.2020	Closed	Home Health and Hospice	When a claim is entered via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) with the Medicare Beneficiary Identifier (MBI), and when pressing F9 a reason code displays, the MBI changes to a Health insurance Claim Number (HICN). If the reason code is resolved, and the claim is stored, the claim is sent to the Return to Provider (RTP) file with reason code 30995 in error.	30995	MBI	02.12.2020
Updates	02.21.2020 – The system fix to resolve this issue was implemented on February 12, 2020. 02.07.2020 – The scheduled implementation date has been changed to February 12, 2020. 01.21.2020 – This issue has been reported and a resolution is scheduled for implementation on March 2, 2020.
MAC Action
Provider Action	02.21.2020 – Providers should now be able to enter the MBI using FISS DDE. 01.20.2020 – This is only affecting claims entered into FISS via DDE. Claims can be submitted electronically.
Proposed Resolution	01.20.2020 – System release is scheduled for implementation on March 2, 2020.

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