Skip to Main Content
LICENSES AND NOTICES

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.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  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.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Impact

Print | Bookmark | Email | Font Size: + |

Reopenings

Medicare Claims Processing Manual (Pub. 100-04, Ch. 34External PDF).

CGS performs four types of reopenings:

Review the information below to determine the correct type of reopening to request, and the appropriate process to follow when submitting the request.

Claim Correction Reopening

When the need for a claim correction is discovered and the claim is beyond the timely filing limit (1 calendar year from the "through" date on the claim), a reopening request (type of bill (TOB) XXQ) must be submitted to remedy the error. When a claim needs correction and the claim is within the timely filing limit, an adjustment (type of bill XX7) may be submitted.

Reopenings are typically used to correct claims with clerical errors, including minor errors and omissions, and are conducted at the discretion of CGS. Minor errors or omissions may include:

  • Transposed procedure/diagnostic codes
  • Incorrect provider number or date of service
  • Inaccurate data entry
  • Mathematical or computational mistakes

Note: Omissions do not include failure to bill items/services, such as late charges. A reopening may be requested to change a claim determination that resulted in an overpayment or underpayment, even though the decision was correct when the claim was processed.
Reopenings are separate from the appeals process, and therefore, do not count towards the five levels of appeal.

Note: Reopenings (TOB XXQ) cannot be submitted with a hardcopy (paper) UB-04. They must be submitted via the 5010 format or entered directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE).

For reopening requests entered via Direct Data Entry (DDE), from the Fiscal Intermediary Standard System (FISS) Main Menu, select Claims Correction (Option 03), then, select the Claim Adjustments options 33 (home health) or 35 (hospice). In addition to the usual field locators and the information being adjusted, reopenings (TOB XXQ) must include the following information. If there is a medically denied line item on the claim, FISS may not allow you to complete the adjustment electronically. If you are unable to submit the reopening electronically or via DDE, you may submit a hard copy adjustment using the Clerical Error Reopening Request FormPDF.

Field Name/Requirement

Description

TOB
(FISS Page 1)

32Q – home health reopening
34Q – home health outpatient reopening
81Q – hospice (nonhospital based) reopening
82Q – hospice (hospital based) reopening

Once the claim being reopened is selected, you must change the third digit of the TOB field to 'Q' to identify the adjustment claim as a reopening request.

COND CODES
(FISS Page 1)

Enter the appropriate condition code.

R1 – Mathematical or computational mistake
R2 – Inaccurate data entry
R3 – Misapplication of a fee schedule
R4 – Computer errors
R5 – Incorrectly identified duplicate
R6 – Other clerical error or minor error or omission (failure to bill a service is not considered a minor error).
R7 – Correction other than clerical error
R8 – new and material evidence is available
R9 – Faulty evidence (initial determination was based on faulty evidence)

COND CODES
(FISS Page 1)

Enter a condition code that best describes what is being changed.

D0 – Changes in service date
D1 – Change to charges
D2 – Changes in revenue code/HCPCS/HIPPS Rate Codes
D4 – Change in clinical codes (ICD) for diagnosis and/or procedure codes
D9 – Change in condition codes, occurrence codes, occurrence span codes, provider ID, modifiers and other changes
E0 – Change in patient status

When D9 is used, an explanation must be included in the REMARKS filed (FISS Page 4). 

COND CODES
(FISS Page 1)

Enter 'W2' (duplicate of original bill) to attest that the reopening request is for a claim already sent to Medicare and there is no appeal in process. A reopening request cannot be submitted if an appeal has been requested, and a decision is pending or in process.

ADJUSTMENT REASON CODE
(FISS page 3)

FISS will automatically assign one of the codes below.
R1 – Less than 1 year from the initial determination (Remittance Advice (RA) date)
R2* – 1 – 4 years from the initial determination (RA date)
R3* – Greater than 4 years from the initial determination (RA date)

*Requires "Good Cause" to be documented by submitting a "Remark".

REMARKS
(FISS page 4)

Remarks are always helpful in processing a reopening; however, the REMARKS field is required when the R2 or R3 Adjustment Reason Code is submitted. Remarks should be formatted for a change or addition (C-A), new and material evidence (NME) and faulty evidence (F-E) with a narrative explanation. NOTE: The first 15 characters of the remark must match exactly as shown below.

  • Good_Cause-_C-A (underline indicates a space)
  • Good_Cause-_NME (underline indicates a space)
  • Good_Cause-_F-E (underline indicates a space)

Example: Good Cause- C-A to add revenue code 0550 because…

If the change or addition affects a line item, please indicate which line(s) is/are being changed.

Resources

Back to the top of the page Top

Untimely Filing

Claims are rejected for untimely filing when the claim is submitted 12 months after the date the services were furnished. The Centers for Medicare & Medicaid have established exceptions to the one calendar year time limit. For additional information, refer to the Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 1, §70.7External PDF. At this time, a hardcopy UB-04 adjustment, or a reopening request may be submitted if one of the exceptions apply.

Reason for Untimely Filing

Submitting Hardcopy Adjustment

Submitting a Reopening – Can only be submitted via 5010 or FISS Direct Data Entry (DDE)

Claim rejected (R B9997 or P B9997) with reason code 39011 due to timely filing edits.

  1. Medicare HHH Reopening Adjustment Request FormPDF
  2. Adjustment claim (XX7) on a hardcopy UB-04 claim form, with the necessary adjustment coding (condition code, DCN, and remarks)
  3. Documentation to support an exception to override timely filing.

NOTE: To determine the correct DCN to report on your adjustment, select the denied claim (TOB 329). Go to Page 02 and press F2. The DCN of the claim will appear in the upper left corner in the "DCN" field.

Requests for untimely filing reopenings, along with supporting documentation, must be mailed to:

J15 – HHH Claims
CGS Administrators, LLC
PO Box 20019
Nashville, TN 37202

Detailed coding information can be found under the "Claim Correction Reporting" heading of this Web page.

  1. TOB with the third digit of "Q", (XXQ)
  2. Condition Codes (R7, R8, or R9)
  3. Condition Code D9 (Other Changes)
  4. Condition Code W2
  5. Adjustment Reason Code (R1, R2, or R3)
  6. Remarks (required when adjustment reason code R2, R3, or condition code D9 are submitted). Refer to the "Remarks" section (above) under the "Claim Correction Reopening" heading.

If additional information is requested by CGS, the reopening adjustment will be RTP'd with a note on the Remarks page. Please note, no letter will be sent by CGS.

Back to the top of the page Top

56900 Reopenings

Claims deny with reason code 56900 when a medical review contractor doesn’t receive your documentation in response to an additional documentation request (ADR) letter within the required timeframe (45 calendar days for CGS). Review the Medical Review Additional Documentation Request Process: Prepayment Review and Postpayment Review pages to learn how to avoid these claim denials.

A 56900 reopening request allows the Medical Review department to complete a review without using the Medicare Appeals process.

When to Submit

  • Claim denied with reason code 56900
  • Within 120 days of the claim denial date
    • After 120 days of the claim denial date, submit a redetermination request (first level of appeal).

How to Submit

What to Submit

  • Completed 56900 reopening request form
  • Copy of the ADR letter
  • Medical record documentation that supports medical necessity of the services billed (as indicated in the ADR letter and/or HH&H Medical Review Activity Log)

Back to the top of the pageTop

Ordering/Referring Denial Reopenings

Claims are denied with reason code 32072, 37236, 37237, or 37247 when the NPI and/or physician's last name or first name submitted on the home health claim does not match the physician's information at the Provider Enrollment, Chain, and Ownership System (PECOS). While claims denied for this reason will appear in status/location D B9997, the claim should be appealed using the Reopening process, rather than the redetermination process.

Avoid Ordering/Referring Denials

To avoid ordering/referring denials, refer to the Ordering/Referring Physician Checklist for Home Health AgenciesPDF quick resource tool and follow the three easy steps.

Reason for Ordering/Referring Reopening

Required Documentation

Claim denied for ordering/Referring physician NPI and/or name

  1. Medicare HHH Reopening Adjustment Request FormPDF
  2. Adjustment claim (XX7) on a hardcopy UB-04 claim form, with the appropriate NPI and physician name, and necessary adjustment coding:
    • Condition code
    • Document Control number (DCN) – NOTE: To determine the correct DCN to report on your adjustment, select the denied claim (TOB 329). Go to Page 02 and press F2. The DCN of the claim will appear in the upper left corner in the "DCN" field.
    • Remarks

Refer to the Adjustments/Claims Web page for additional information.

Requests for ordering/referring denial reopenings, along with a hardcopy UB-04, must be mailed to:

J15 – HHH Claims
CGS Administrators, LLC
PO Box 20019
Nashville, TN 37202

Back to the top of the page Top

Updated: 10.20.23

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © 2024 CGS Administrators, LLC. All Rights Reserved