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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Submitting Medicare Secondary Payer (MSP) Claims and Adjustments

When your dates of service fall within the Effective and Termination dates of an MSP record, the claims must acknowledge the MSP record by reporting appropriate MSP coding on your claim.

MSP claims are submitted using the ANSI ASC X12N 837 format, or by entering the claim directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE). If you need access to FISS in order to enter claims/adjustments via FISS DDE, contact the CGS EDI department at 1.877.299.4500 (select Option 2).

Submitting MSP Claims via FISS DDE or 5010

All MSP claims submitted via FISS DDE or 5010 must report claim adjustment segment (CAS) information. In FISS DDE, the CAS information is entered on the "MSP Payment Information" screen (MAP1719), which is accessed from Claim Page 03 by pressing F11. This is in addition to the normal MSP coding information. CAS information on MSP claims submitted via 5010 format is reported in Loops 2320 – 2330I. Refer to the table below for additional information.

The CAS information associated with the primary payer's claim determination is found on the primary payer's 835 remittance advice. This information is entered on the "MSP Payment Information" screen, which accommodates up to 20 entries for primary payer 1, and 20 entries for primary payer 2 (if there is one).

For detailed instructions on reporting other MSP required data elements (value codes, occurrence codes, primary insurer information, etc.) refer to the CGS 'Medicare Secondary Payer (MSP) Billing and Adjustments' quick resource tool or the 'Medicare Secondary Payer (MSP) Billing and Adjustments' Online tool.

FISS MAP1719 - MSP Payment Information Screen

Field Name

Description

5010 Format

PAID DATE

Enter the paid date shown on the primary payer's remittance advice.

2330B DTP segment Primary Adjudication or Payment Date

PAID AMOUNT

Enter the paid amount shown on the primary payer's remittance advice. This amount must equal the dollar amount entered for MSP Value Code 12, 13, 14, 15, 41, 43 or 47.

2320 AMT segment Primary Payer Paid Amount

GRP

Enter the Group Code shown on the primary payer's remittance advice.

CO - Contractual Obligation
PI - Payer Initiated Reductions
OA - Other Adjustment
PR - Patient Responsibility

Note: If CARC code 45 is entered, the Group code must be “CO” (contractual obligation) or “PR” (patient responsibility).

2320 CAS segment Claim Level Adjustments
CAS01 CO PR OA

CARC

Enter the Claim Adjustment Reason Code (CARC) shown on the primary payer's remittance advice. If CARC code 45 is entered, the Group code must be “CO” (contractual obligation) or “PR” (patient responsibility).

Note: CARC codes explain why there is a difference between the total billed amount and the paid amount. The word 'adjustment' in relation to a CARC code is not the same as a "claim" adjustment (type of bill 327 or 817)

For a current list of valid CARC codes, refer to the Washington Publishing Company website.

You can also search through a list of CARC codes by accessing the FISS DDE Inquiry screen option 68 (ANSI REASON CODES) and type "C" in the RECORD TYPE field.

2320 CAS segment Claim Level Adjustments
CAS02 Adjustment Reason Code
CAS05, CAS08, CAS11, CAS14, CAS17 if multiple CARCs for the same group code

AMT

Enter the dollar amount associated with the group code (GRP) and CARC.

NOTE: If VC 44 (obligated to accept as payment in full) is submitted, the AMT field for GRP ‘CO’ and CARC ‘45’ should equal the difference between the total billed and the VC 44 amount. Using the example below, the VC 44 amount was $1433.00.

The total amount entered in the PAID AMOUNT field, plus the adjusted amount(s) entered in the AMT field for each GRP and CARC combination, must equal the total submitted charges on the claim.

The screen print example below indicates:

Primary insurer paid $800.01 on November 2nd
$217.01 – contractual adjustment (GRP – CO, CARC – 45)
$232.99 – coinsurance (GRP – PR, CARC – 2)
$400.00 – deductible (GRP – PR, CARC – 1)

The total amount billed (revenue code 0001) was $1650.01

PAID AMOUNT	plus	AMT (adjusted charges)	equals	Total Billed
$800.01	+	$217.01 + $400.00 + $232.99	=	$1650.01

2320 CAS segment Claim Level Adjustments
CAS03 Adjustment Amount
CAS06, CAS09, CAS12, CAS15, CAS18 if multiple CARCs for the same group code

Press F6 to access the "MSP Payment Information" screen for primary payer 2 (if there is one).

Press F5 to move back to the primary payer 1 "MSP Payment Information" screen.

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Additional Information

Paper (UB-04) claims can only be submitted to CGS for Black Lung related services, or when a provider meets the small provider exception, (CMS Pub. 100-04, Ch. 24 §90).
When a beneficiary is entitled to benefits under the Federal Black Lung (BL) Program, and services provided are related to BL, a paper (UB-04) claim must be submitted with MSP coding and the denial notice from the Federal BL Program. If applicable, also provide the workers' compensation insurer denial notice. If the services provided are not related to BL and does not include a BL related diagnosis code, the claim can be submitted via 5010 or FISS DDE showing Medicare as the primary payer.
When submitting non-group Health Plan (no fault, liability, worker's compensation) claims for services unrelated to the MSP situation, and no related diagnosis codes are reported, do not include any MSP coding on the claim.

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Correcting MSP Claims and Adjustments

Return to Provider (RTP): MSP claims may be corrected out of the RTP file (status/location T B9997). However, providers must ensure that claim adjustment segment (CAS) information is reported on the "MSP Payment Information" screen (MAP1719), accessed from Claim Page 03 by pressing F11.

Adjustments: Providers may submit adjustments to MSP claims via 5010 or FISS DDE. However, if using FISS DDE, as with claims in RTP, providers must ensure the MSP information is entered on the "MSP Payment Information" screen. Refer to the Adjustments/Cancels Web page for more information about submitting adjustments.

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References

Change Request 8486 - Instructions on Using the Claim Adjustment Segment (CAS) for Medicare Secondary Payer (MSP) Part A CMS-1450 Paper Claims, Direct Data Entry (DDE), and 837 Institutional Claims Transactions
CMS Medicare Secondary Payer Manual (Pub. 100-05) Ch. 5 §40.7.3.2

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Updated: 12.17.20