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 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

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Hospice Cap

The Fiscal Year (FY) 2015 Hospice Wage Index and Payment Rate Update included a requirement for hospices to file a self–determined hospice aggregate cap. Refer to the following topics for additional information.

Timeline
Terminated Providers
Provider Statistical and Reimbursement (PS&R)
Forms and Instructions
Calculation for Newly Medicare-Certified Hospices
Submitting Cap Determinations
Cap Overpayments
Receipt Confirmation
Sequestration

Timeline

Hospices are required to file a self-determined cap no earlier than 3 months, and no later than 5 months after the end of the hospice cap year, September 30. The earliest a hospice may file its self-determined cap is December 31, and the latest is February 28 of each year.

Terminated Providers

CMS issues 2 years' worth of the Statuary Cap amount at a time, effective with the 9/30/17 Self-Determined (SD) cap submissions. Providers who terminate from the program in the following cap year (i.e., 2024) must submit both the Current Year (i.e., 2023) and their final (terminating) SD cap reviews at the same time. After CGS processes the current year SD cap submissions, we will complete all necessary final cap reviews for your agency. The Statuary Cap Amount for 2024 is $33,494.01. Please note: CGS must receive notice of and process the termination before you can submit your final (terminating) SD cap.

Provider Statistical and Reimbursement (PS&R)

To prepare the cap calculation, hospices should obtain their Provider Statistical and Reimbursement (PS&R) summary and Hospice Cap reports from the CMS website. Instructions are available to assist you.

CGS does not send copies of PS&R reports since hospices are responsible for obtaining these reports directly from the PS&R System. However, if you are unable to obtain this information, you may contact Tom Bisbee at 615.660.5560 for assistance.

Forms and Instructions

To complete your self-determined hospice aggregate cap, you must complete the "Provider Self-Determined Aggregate Cap Limitation" form.

Instructions for completing this form are also available.

Calculation for Newly Medicare-Certified Hospices

The hospice aggregate cap is calculated in a different manner for new hospices that enter the Medicare program and do not participate for an entire cap year. In this situation, the initial cap calculations for newly certified hospices must cover a period of at least 12 but less than 24 months.

For example, the first cap period for a hospice that entered the program on September 1, 2022, is September 1, 2022, through September 30, 2023. Order your PS&R Summary and Hospice Cap reports from the agency's tie-in date to September 30 of the second cap year (i.e., September 1, 2022 – September 30, 2023). To obtain the correct beneficiary count from the Hospice Cap report, add the count from the 2022 and 2023 cap years.

You will also need to calculate a prorated Hospice cap amount. Provider entry is required in all gray shaded boxes of this form.

Submitting Cap Determinations

Send your completed "Provider Self-Determined Aggregate Cap Limitation" form, cover letter, and all supporting documents to one of the following:

Mailing Address	Email Address	Fax Number
Part A/HHH Audit & Reimbursement CGS Administrators, LLC PO Box 20015 Nashville, TN 37202	SDHOSPICECAPS@cgsadmin.com	615.660.5983 Attn: Tom Bisbee

IMPORTANT NOTE: If CGS does not receive the self-determined cap within 7 days of the end of February/1st few days of March due date, we will issue a Past Due letter and suspend payments.

Cap Overpayments

For any overpayment amount calculated as a result of the self-determined cap, send a check made payable to CGS with a cover letter that explains what the payment is for to the following address:

CGS
P.O. Box 957124
St. Louis, MO 63195-7124

If you do not submit the overpayment at the same time as the self-determined aggregate cap, CGS shall demand the overpayment reported on the self-determined aggregate cap.

Receipt Confirmation

Upon receipt, CGS will perform a cursory review of the filed self-determined cap for obvious errors. Within 45 days of receipt, Hospices will receive a letter from CGS to confirm receipt of the filed self-determined aggregate cap calculation.

CGS will perform a final review of the filed calculation at a later date.

Sequestration

For information about how sequestration amounts are handled pertaining to the hospice cap calculation, refer to the "Sequestration – Impact on Hospice Aggregate Cap Calculations" article.

Updated: 12.29.23