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

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

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June 25, 2013 - Updated 11.15.16

Medical Record Requests: Keys to Success

You may receive requests for medical records from Medicare for a variety of reasons. Requests may also come from several different Medicare contractors. Record requests may be related to any of the following:

  • Comprehensive Error Rate Testing (CERT) program
  • "Additional Documentation Request" letters (ADR letters): more information is required before the Medicare contractor can process the claim. Examples:
    • Review of a new physician or practitioner to ensure a good understanding of Medicare claim submission and documentation guidelines
    • Review of an established physician or practitioner, before or after the claim is paid, based on analysis of data
  • Investigation of a complaint alleging possible fraud or abuse of the Medicare program
  • Review of services by the Recovery Auditor (RA)

Keys to success:

  • Send all relevant documentation, but only the relevant documentation.
  • Send it on time
  • Send it to the right entity / address or fax number
  • Include a copy of the request letter with your submission

Note: Your facility may have designated a single point of contact or coordinator for medical record requests from Medicare contractors.

We recommend that you check with your compliance officer or manager before submitting records or transferring the request to another department. Your office or facility may have specific internal guidelines; CGS offers this guidance to supplement your own processes and procedures.

Reason for Request Last Date to Submit Records Return the Records To
Review of medical records, through the CERT program Initial Requests – 75 days from the date on the letter

Additional Documentation Requests (tech stops) – 45 Days
CERT Documentation Contractor (CDC)

Fax records with CID and bar code sheet to (240) 568-6222.

Physical address for CDC:
CERT Documentation Office
Attn CID # ________
9090 Junction Drive, STE 9
Annapolis Junction, MD 20701
More information is required before Medicare can process the claim.

The claim has not yet been paid. This is called an additional documentation request letter (ADR).
30 days from the date on the letter CGS

The address will be listed in the body of the letter.
Review of records for a new physician or practitioner before the claim is paid 30 days from the date on the letter CGS

The address will be listed in the body of the letter.
Review of claims by the Recovery Auditor (RA) 45 days from the date on the letter Electronically, via the Electronic Submission of Medical Documentation (esMD) process or in a CD or DVD: refer to the document "Medical Record Submission Instructions: Medicare's CGI RAC Region BExternal PDF" for complete instructions

By fax: 1.216.902.3860

By mail:
CGI Federal Inc.
Attn: RACB Imaging Dept
1001 Lakeside Ave., Suite 800
Cleveland, OH 44114

Review of an established physician or practitioner before the claim is paid 30 days from the date on the letter CGS

The address will be listed in the body of the letter.
Review of an established physician or practitioner after the claim was paid 30 days from the date on the letter CGS

The address will be listed in the body of the letter.
Investigation of a complaint alleging possible fraud or abuse May vary (refer to specific letter for details) Cahaba Safeguard Administrators, LLC The address will be listed in the body of the letter.

It is also vital that you include all of the requested records. Before responding to the request, double-check to ensure that you have included all relevant information, such as:

  • If the request is for a physician or nonphysician practitioner (NPP) visit (Evaluation and Management service, or E/M service) include documentation for that encounter along with the following:
    • If the physician/NPP's note refers to an earlier encounter date (such as a prior history or list of prescription medications), include copies of the earlier note as well as information pertinent to the date requested.
    • If the physician/NPP's note refers to results of a lab or other diagnostic test, include the test results with the requested information.
    • If the physician/NPP's note refers to a form completed by the patient listing his or her symptoms or past history, copy this form along with the physician's notes.
  • If the physician or practitioner's signature is not legible, provide a signature log with the practitioner's typed/printed name and handwritten signatures for authentication of illegible signature, or provide a signature attestation form (CGS has an example formPDF).
  • If the service was provided based on an order, provide documentation of the order. This is especially important for clinical laboratory tests and diagnostic services, including x-rays and EKGs. Include with the order the office/progress note documenting the medical necessity of the service.
  • If the physician or practitioner uses abbreviations that are not common, provide a key.
  • If the patient signed an Advance Beneficiary Notice of Non-coverage (ABN), include a copy with the requested records.
  • If the service is the physician's interpretation of a diagnostic test (e.g., EKG or X-ray) provide his or her complete interpretation and copies of the test results. Do not send original X-ray films or other original records.
  • If the documentation resides with a third party (i.e. hospital, SNF) it is your responsibility to obtain copies for submission.

Other Tips:

  • Each letter from Medicare requesting medical records will be on CMS letterhead or CGS letterhead and will include a telephone number. If you are unsure what information is being requested, call the number and ask questions to clarify.
  • If the medical records are two-sided, copy both sides before sending copies to the requesting entity
  • When responding to a CERT request always write the Claim Identifier (CID) number on the medical record. The CID number can be found on your request letter.
  • You may respond to medical record requests from Medicare contractors without having the patient sign additional HIPAA release forms. The patient's signature on file or his/her signature on the Medicare claim authorizes release of the records to a Medicare contractor upon request.
  • If the request is from CGS and you have additional questions, please call the number listed in the letter. If you cannot locate the telephone number in the letter, please call us:
    • 615.782.4591
  • If the request is from Cahaba Safeguard Administrators, call the specific telephone number listed in the letter.
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