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.

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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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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.
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Home Health Demand Denials (Condition Code 20)

A demand denial allows a beneficiary to request that Medicare review services that:

their HHA advised them were not medically reasonable and necessary; or
failed to meet the homebound or intermittent, or noncustodial requirements, and therefore, would not be reimbursed if billed.

NOTE: If the Advance Beneficiary Notice (ABN) was provided because the services do not meet the Medicare covered benefit definition (i.e. routine foot care) or are custodial in nature (housekeeping or home health aide services) and the beneficiary has authorized billing Medicare, the HHA should submit a no-pay bill using condition code 21.

The HHA must inform the beneficiary of their decision with an ABN, which also must be signed by the beneficiary or appropriate representative before any services are provided. The ABN provides the beneficiary with the option to have a demand denial (condition code 20) submitted to Medicare for review. The HHA must comply with the beneficiary's request to submit a demand bill (condition code 20).

Demand denials must be submitted promptly once the last billable service is provided and the physician's signature has been obtained for all orders. Beneficiaries may pay out of pocket or third party payers may cover the services in question. All demand denials will be subject to medical review through the additional development request (ADR) process. Home health agencies will need to monitor the Fiscal Intermediary Standard System (FISS) and return the patient's medical information to CGS when the demand bill is in FISS ADR status/location S B6001. See the CGS Additional Development Request (ADR) Process Web pages for more information on ADRs.

If medical review upholds the HHA's decision that the services were not coverable, the HHA keeps the funds collected from the beneficiary. However, if CGS determines the ABN notification was not properly executed, or some other factor changed liability for payment of the disputed services to the HHA, the HHA must refund any funds collected. HHAs must also refund any monies collected if medical review determines that the services were payable by Medicare.

See the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 50)for additional information on demand billing under the Home Health Prospective Payment System (HH PPS). The link to access this resource is at the bottom of this page.

Billing Requirements

In demand denial situations, a Notice of Admission (NOA) is required to be billed as usual; do not submit the NOA with condition code 20. The condition code of 20 would be submitted on the final claim. The NOA will process and will be posted to the beneficiary eligibility record housed at the Common Working File (CWF). Demand denial (condition code 20) information is submitted on home health claims with a TOB (type of bill) 329 and includes all the required information including all visit-specific detail for the entire home health period of care. Please note that TOB 3X0 is no longer valid for demand bills where condition code 20 is used.

The following information must also be provided on a demand bill.

Condition code 20
Charges for services in dispute shown as covered and noncovered
Remarks indicating the reason for the demand denial (condition code 20)

Additional Resources

Medicare Claims Processing Manual(Pub. 100-04, Ch. 10, § 50)- CMS issued instructions for demand bills
Demand Billing Information Sheet for Home Health Providersquick resource tool
Beneficiary Notices InitiativeWeb page
CGS Advance Beneficiary Notice of Noncoverage (ABN) Web page
CMS Advance Beneficiary Notice of Noncoverage (ABN) Booklet
Medicare Learning Network (MLN) Matters® article MM8404"Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131"
Medicare Claims Processing Manual (Pub. 100-04, Ch. 30, § 50)- instructions for the ABN
Medicare Learning Network (MLN) Matters® article MM7660, "Additional Instructions Regarding Demand Bills Under the Home Health Prospective Payment System"
MLN Matters® article, MM7865, "Erroneous Partial Episode Payment Adjustments on Certain Home Health Dual-Eligible Claims"

Updated: 02.03.22