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.


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Home Health Expedited Determination Process

Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 30, §60.2.B & 260)External PDF

Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 1, §150.3)External PDF

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

When a home health agency (HHA) determines that the beneficiary's Medicare-covered home health services are ending, they are required to provide a Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) to the beneficiary at least:

  • Two calendar days before Medicare covered services end; or
  • The second to last date of service (if care is not being provided daily).
  • For home health providers, this means the notice must be delivered no later than the next to last visit before Medicare covered services end.

Exception: When a home health beneficiary is found to no longer be homebound, the NOMNC should be provided to the beneficiary immediately.

Note: When home health services end because of physician's orders, HHAs have the option of issuing the NOMNC alone or both the NOMNC and the HHCCN. Refer to the Home Health Change of Care Notice (HHCCN) Web page for additional information about the HHCCN.

A NOMNC is not required when:

  • A beneficiary chooses to end the Medicare-covered services they are receiving;
  • Service are being reduced (e.g., HHA providing physical therapy and occupational therapy discontinued the occupational therapy);
  • A beneficiary moves to a higher level of care (e.g., home health care ends due to beneficiary being admitted to a skilled nursing facility);
  • A beneficiary chooses to transfer to another HHA during an episode while still receiving home health services from them; or
  • A HHA discontinues care for business reasons.

The NOMNC allows the beneficiary to appeal the HHA's decision to discharge them. A beneficiary who disagrees with the termination of services may request an expedited determination from a Quality Improvement Organization (QIO.)

The QIO is responsible for notifying the HHA of a beneficiary's request for an expedited determination. By close of business that day, the HHA must then give the Detailed Explanation of Non-Coverage (DENC) (CMS 10124) to the beneficiary. The DENC provides a more detailed explanation of why coverage is ending. The HHA must also supply the QIO with copies of the NOMNC and DENCs as well as all information, including medical records, that the QIO requests by close of business, that day. HHAs may choose to give both notices to the beneficiary at the same time.

Note: Upon the QIO's notification of an expedited determination, the HHA may telephone the beneficiary to provide the information contained on the DENC, annotate the DENC with the date and time of telephone contact, and file it in the beneficiary's record. A hard copy of the DENC should be sent to the beneficiary via tracked mail or other personal courier method by close of business of the day the QIO notifies the HHA.

Forms and Instructions

The NOMNC (CMS 1023) and DENC (CMS 10124) forms, as well as instructions for completing these forms, are available on the Centers for Medicare & Medicaid Services (CMS) 'FFS Expedited Determination NoticesExternal WebsiteWeb page under the "Downloads" section of the page. CMS has contracted with QIOs to review the beneficiary's appeal of discharge. A listing of the QIOs for each state may be accessed via the QIO Listing link under the "Additional Resources" section below.

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 HHA and beneficiary are notified.

QIO Decision

When a QIO decision is favorable to a beneficiary without physician orders, the ordering physician should be made aware the QIO has ruled coverage should continue, and be given the opportunity to reinstate orders. The beneficiary may also choose another personal physician to write orders for care as well as find another service provider.

If covered home health care continues following a favorable QIO decision for the beneficiary, the HHA would resume issuance of Advance Beneficiary Notices (HHABN) and the HHCCN as warranted for the remainder of the home health episode.

When the HHA submits their claim to Medicare following a favorable QIO decision, the 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 an additional development request (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

Additional Resources

Updated: 12.10.19

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