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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.
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Hospice Expedited Determination Process

The expedited determination process is afforded to Medicare beneficiaries to dispute the end of their Medicare covered care in certain settings, including hospice care.

When a hospice agency determines that all Medicare covered hospice services are going to end for a beneficiary, the hospice must provide the beneficiary with the Notice of Medicare Non-coverage (NOMNC) (CMS-10123) at least:

  • Two calendar days before Medicare covered services end; or
  • The second to last day of service (if care is not provided daily).

Note: A NOMNC is not required in situations where the beneficiary has chosen to revoke their hospice benefits, or in cases where the beneficiary transfers to another hospice agency.

The NOMNC allows the beneficiary to appeal the hospice's decision to discharge them. A beneficiary who disagrees with the termination of services may request an expedited determination to the Quality Improvement Organization (QIO). The QIO is responsible for notifying the hospice that the beneficiary has requested an expedited determination.

Once the QIO notifies the hospice of the expedited determination request, the hospice must furnish the Detailed Explanation of Non-Coverage (DENC) (CMS-10124) to the beneficiary by close of business that day. The DENC provides a more detailed explanation of why coverage is ending. The hospice must also supply the QIO with copies of the NOMNC and DENC, as well as all information, including medical records, that the QIO requests.

The NOMNC (CMS 10123) and the DENC (CMS 10124) forms, as well as instructions for completing these forms, are available via links on the bottom of the Centers for Medicare & Medicaid Services (CMS) 'FFS Expedited Determination Notices' Web pageExternal Website, under the section titled 'Downloads'.

Generally, the QIO must make their determination on whether the discharge is appropriate within 72 hours of their receipt of the beneficiary's request for a review. Once the QIO decision has been made, the hospice and beneficiary are notified.

If the QIO extends coverage to a period where a physician's orders do not exist, the hospice cannot provide care. If the QIO decision is favorable to the beneficiary without physician orders, the ordering physician should be made aware of the QIOs decision, and given the opportunity to reinstate the orders. The beneficiary can also see other personal physicians to write orders, or find another service provider. The expedited determination process does not override regulatory or State requirements that physician orders are required for a provider to deliver care.

If the hospice continues to provide services to the beneficiary following a favorable QIO decision, the hospice claim must include a condition code, which notifies CGS of the QIO's decision. The QIO's decision is limited to the discharge decision, and is binding. However, the claim may still be selected by CGS's Medical Review department for a medical review additional development request (MR ADR), as the medical review process examines a much broader range of Medicare coverage regulations. Appropriate billing of the condition code on a QIO-reviewed claim ensures that the QIO's decision is considered during the medical review process. See the table below for a list and description of each condition code applicable to a QIO expedited determination decision.

Condition Code Description Used When The Claim Was Reviewed, And Also Report:
C3 Partial approval of Medicare-covered services
  • Some days of the stay or services were denied.
  • Occurrence span code (OSC) M0 in FL 35-36 and the From and To dates of the approved stay.
C4 Services denied
  • All services beyond the intended discharge date were denied.
  • OSC 76 in FL 35-36 in cases where the beneficiary may be liable for payment and the dates of service, denoting the patient liability period.
  • An appropriate patient status code indicating the patient's status with your agency as of the claim's "TO" date.
C7 Extended authorization of Medicare-covered services
  • An authorization for extending Medicare coverage for the services being provided was granted.
 

For additional information about the expedited determination process, refer to the Medicare Claims Processing Manual (CMS Pub. 100-04) Ch. 30, §260External PDF.

Resources:

Reviewed: 12.08.21

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