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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Adjustments/Cancels

Submitting an adjustment or a cancel to a claim can be submitted electronically, or via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE).  In addition to the usual claim information, below you will find what fields are required on the UB-04 and in FISS DDE on adjustments and cancel claims.  For additional information about adjusting/canceling claims using FISS DDE, refer to the FISS DDE Guide, Chapter Five: Claims CorrectionPDF.

Adjustment claims (type of bill XX7) are submitted when it is necessary to change information on a previously processed claim. The change must impact the processing of the original bill or additional bills in order for the adjustment to be performed. The claim being adjusted must be in a finalized status location (i.e., P B9997 or R B9997).

If a claim in a P status has been reviewed by Medical Review and has one or more line items denied, adjustments can be made to the paid line items. Please note: Adjustments cannot be made to any part of a denied line item on a partially paid claim.

In addition, only rejected claims (R B9997) that have posted information to the Common Working File (CWF) should be adjusted, such as a claim that rejected due to an open Medicare Secondary Payer (MSP) record or a home health date of service that overlaps a beneficiary's stay in an inpatient facility.

It is not appropriate to adjust home health Requests for Anticipated Payment (RAPs). Incorrect RAPs with an incorrect date of admission must be canceled and rebilled with the correct information. A hospice election date on a Notice of Election (NOE) or a revocation date on a Notice of Termination/Revocation may be corrected.  Refer to the following web pages for additional information.

Adjustment claims must include the following information, in addition to the usual field locators and the information that you are adjusting:


Data
UB-04 Fiscal Intermediary Standard System (FISS)
Form Locator (FL) Data Field
(FISS Page #)
Data
Type of Bill FL 4 3rd digit = 7
327-home health
817 or 827-hospice
TOB (FISS Page 01) 3rd digit = 7 (done automatically by FISS)
Claim Change Reason Code FL 18-28

Choose the one claim change reason code that best describes the adjustment request.

D0 – change dates of service
D1 – change charges
D2 – change revenue/HCPCS code
D7 – Change to make Medicare secondary
D8 – Change to make Medicare primary
D9* – Other/multiple changes
E0 – change patient status *

When D9 is used, an explanation of the adjustment must be included in the Remarks field (FL 80).  The adjustment request will be suspended for review.

COND CODE (FISS Page 01)

D0 – change dates of service
D1 – change charges
D2 – change revenue/HCPCS code
D7 – Change to make Medicare secondary
D8 – Change to make Medicare primary
D9* – Other/multiple changes
E0 – change patient status

* When D9 is used, an explanation of the adjustment must be included in the Remarks field (FISS Claim Page 04).

Document Control Number FL64 Document Control Number (DCN) of the claim being adjusted DCN (FISS Page 01) DCN of claim being adjusted (done automatically by FISS when using Claim Adjustments option 33 or 35)
Total Charges FL 47 Enter changes to charges. TOT CHARGE (FISS Page 02) N/A unless adjusting a rejected claim. If rejected, all revenue code lines must be deleted and rekeyed to show charges as covered (TOT CHARGE field).
Adjustment Reason Code N/A   ADJUSTMENT REASON CODE (FISS Page 03) RF – change dates of service
RG – change charges
RH – change revenue/HCPCS code
RM – Other/multiple changes
RN – change patient status
Remarks FL 80 Remarks indicating reason for adjustment (required when Claim Change Reason Code D9 is reported) REMARKS (FISS Page 04) Remarks indicating reason for adjustment (required when Claim Change Reason Code D9 is reported)

Cancel claims/RAPs (type of bill XX8) may be necessary when the incorrect provider number was submitted, an incorrect Medicare ID number was submitted, or a duplicate payment was received. Home health agencies may need to cancel RAPs for reasons such as removing an episode from the CWF that was submitted and processed with an incorrect service date on the 0023 line.

Claims/RAPs needing canceled must be in a finalized status/location (P B9997). Due to a change in the way FISS processes provider-submitted cancels to rejected claims, home health and hospice agencies will need to check FISS using Inquiry Option 12 to ensure their cancel has finalized prior to resubmitting the services to Medicare.

Cancel claims/RAPs must include the following information, in addition to the usual field locators:

Data UB-04 Fiscal Intermediary Standard System (FISS)
Form Locator (FL) Data Field
(FISS Page #)
Data
Type of Bill FL 4 3rd digit = 8
328-home health
818 or 828-hospice
TOB (FISS Page 01) 3rd digit = 8 (done automatically by FISS)
Claim Change Reason Code FL 18-28 D5 – cancel to correct provider/Medicare ID number
D6 – cancel duplicate payment
COND CODE (FISS Page 01) D5 – cancel to correct provider/Medicare ID number
D6 – cancel duplicate payment
Document Control Number FL64 Document Control Number (DCN) of the claim being canceled DCN (FISS Page 01) DCN of claim being canceled (done automatically by FISS when using Claim Adjustments option 53 or 55)
Adjustment Reason Code N/A   ADJUSTMENT REASON CODE (FISS Page 03) RI – cancel to correct provider/Medicare ID number
RJ – cancel duplicate payment
Remarks FL 80 Remarks indicating reason for cancel REMARKS (FISS Page 04) Remarks indicating reason for cancel

Reopenings

CGS performs four types of reopenings:

  • Claim Correction Reopening (beyond the claims timely filing limit);
  • Untimely Filing (rejected claims (R B9997) with reason code 39011)
  • 56900 Reopenings (denials due to no medical review additional development request (ADR) documentation received by CGS); and
  • Ordering/Referring Denial Reopenings (home health only).

Review the information available on the Reopening webpage to determine the appropriate process to follow when submitting these types of requests.

Limitation on Recoupment (935) Overpayments

The limitation on recoupment (935), as required by Section 935 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) changes the process by which CGS can recoup an overpayment resulting from a post payment adjustment, such as a denial or Medicare Secondary Payer (MSP) recovery. For additional information, refer to the Medicare Financial Management Manual, (CMS Pub. 100-06), Ch. 3 §200External PDF.

Resources

Updated: 11.25.20

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