Skip to Main Content
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.


Impact

Print | Bookmark | Email | Font Size: + |

Requesting an Exception for an Untimely NOE

When the receipt date (REC DT) on your notice of election (NOE) is more than 5 days after the admit date (ADM DT), your NOE is considered untimely, and those days, from admission to the day before the NOE was received, are not payable by Medicare. However, there are some circumstances in which an exception may be granted for the untimely days.

Four Exceptions

Medicare guidelines allow for four exceptions if a hospice NOE is not filed timely. Hospices can provide sufficient information in the REMARKS field (FISS Page 04) that clearly indicates all the circumstances and time frames supporting the exception request. Refer to the "Requesting an Exception" information below.

  1. Fires, flood, earthquakes, or other unusual events that inflict extensive damage to hospice's ability to operate
  2. An event that produces a data filing problem due to CMS or contractor system issues, beyond the control of the hospice
  3. Newly Medicare-certified hospice that is notified of certification after Medicare certification date, or awaiting user ID from Medicare contractor; or
  4. Other circumstances determined by the Medicare contractor (i.e. CGS) or CMS to be beyond hospice's control
    • An exception will be granted in situations when supporting documentation shows that the NOTR was submitted with an incorrect discharge date, causing all previously submitted claims and the original NOE to be canceled (backed out). Because of the limitation of the claims processing system, this situation is beyond the hospice's control. Note: If the original NOE was not timely-filed, the original payment liability will stand.
    • A retroactive Medicare entitlement qualifies as one of the exceptions if a hospice NOE is not filed timely. However, the exception will only be granted with the following supporting documentation.
    • SE1633 indicates that inadvertent errors that cannot be immediately corrected due to the CMS system constraints qualify for an exception in the following circumstances. These guidelines are effective with claims received with exception requests (KX modifier) on or after November 16, 2016.
      • When an NOE is returned for correction (RTP), the NOE may be resubmitted within 2 business days.
      • When the NOE is posted to the Common Working File (CWF), and must be cancelled and resubmitted, 2 business days will be allowed to cancel the NOE and 2 business days will be allowed to submit a new NOE after the date the cancelled NOE finalizes.

Acceptable Exception Examples

  • A hospice required to remove a timely filed NOE to allow a prior hospice to bill.
  • A timely filed NOE that was returned (RTPd) due to an open prior hospice benefit period.

Refer to the Examples of Denied/Granted Exception Requests Web page for detailed examples.

Unacceptable Exception Examples

  • Hospice personnel issues
  • Internal IT system issues
  • Lack of knowledge of requirements

Refer to the Examples of Denied/Granted Exception Requests Web page for detailed examples.

Note: All exception requests are considered on a case-by-case basis.

Back to the top of the page Top

Requesting an Exception

If you believe the reason for your untimely NOE meets one of the exceptions above, submit your claim indicating the untimely NOE (see the Submitting Claims for Untimely NOEs webpage) and include a 'KX' modifier on the noncovered level of care line.

Important Point: The 'KX' modifier, alone, indicates you are requesting an exception for the untimely NOE.

screen shot

Hospices can provide sufficient information in the REMARKS field (FISS Page 04) that clearly indicates all the circumstances and time frames supporting the exception request. When inadvertent errors occur that cannot be immediately corrected due to the CMS system constraints, the information in the REMARKS field must include:

  1. When the original NOE was submitted;
  2. When the NOE was returned to the hospice (RTPs) for correction or was accepted and available for correction; and
  3. When the hospice resubmitted the NOE.
If the information in the REMARKS field is not clear, CGS will request documentation by generating a non-medical review additional development request (non-MR ADR). The hospice will need to submit documentation supporting the exception request (e.g., printouts or screen prints of Medicare systems) for the untimely NOE. For information about supporting documentation, refer to the "Submitting Documentation for Exception Requests" section further down on this page.

For an exception request for an individual who receives retroactive Medicare entitlement, the following documentation must be submitted:

Back to the top of the page Top

Identifying a non-MR ADR for an Exception Request

If the information in the REMARKS field is not clear, a non-MR ADR will be generated and the exception request claim will move to a status/location S B6001, and include a reason code 39701 (see screenprint below). Providers are responsible for checking for the ADR'd claim – no other notification will be sent to the provider.

For detailed instructions on how to check for ADRs using the FISS system, refer to the 'Accessing Additional Development Request (ADR) Information' section in the FISS Guide Chapter 3: Inquiry MenuPDF.

screen shot

FISS Page 07 (below) provides the DUE DATE by which the documentation must be received. However, CGS recommends submitting your documentation as soon as possible which will assist with the prompt processing of your claim to avoiding unnecessary delays. If your documentation is not received by the DUE DATE indicated, your claim will be released to process as it was submitted, with the noncovered days due to the untimely NOE.

screen shot

FISS Page 08 (below) indicates the ADR edit code '78877'. This code is specific to claims where documentation is being requested due to an exception request for an untimely NOE. Page 08 provides:

  • The ADR narrative, indicating the need to submit documentation to support exceptional circumstance NOTE: Only documentation related to the exceptional circumstance should be submitted.
  • The methods to submit supporting documentation to CGS.

screen shot

You will need to press the 'F6' key to view additional instructions for submitting your documentation, including the fax number and mailing address. Faxes are preferred, as that will reduce the amount of time your claim is held, pending receipt of the documentation.

Back to the top of the page Top

Submitting Documentation for Exception Requests

If the information in the REMARKS field is not clear, and you need to submit documentation to CGS, we suggest that you include a screen print of FISS Page 08, so the documentation can be associated with the exception request for the specific patient and claim. If CGS is unable to match the documentation to a specific claim, the exception request will be denied. Documentation may be submitted one of the following ways:

Note: The mailing address and fax number are different than those typically used for sending documentation to the CGS Medical Review department. Sending exception request documentation to the incorrect fax number or address will cause delays in the review process.

Important points when submitting your documentation:

  • Do send the necessary documentation (screenprints, notes, documented phone calls, etc.) that supports the exception request, and the reason this is beyond the hospice's control.
  • Do include a contact name and phone number in case CGS needs to contact your agency.
  • Do send only the documentation related to the untimely NOE.
  • Do not submit all medical record documentation related to the services provided.
  • Do not submit your documentation to CGS more than once. Sending your documentation via multiple methods causes a duplication of effort by CGS staff, and can result in unnecessary delays in reviewing your documentation.
  • Do include the following information in the REMARKS field (Claim Page 04) when an inadvertent error occurs that could not be immediately corrected due to the CMS system constraints.
    • When the original NOE was submitted;
    • When the NOE was returned to the hospice (RTPs) for correction or was accepted and available for correction; and
    • When the hospice resubmitted the NOE.

If your documentation is not received within 30 days of the initial request, it will be moved to a holding location, S M8877, until day 45 or until your documentation is received. If your documentation is not received by day 46, the claim will be released to process as billed, with the untimely days as noncovered.

Back to the top of the page Top

Acknowledgement of Documentation Receipt

Once your documentation is received by CGS:

  • The claim will be moved to status/location 'S M87DR'
  • The documentation will be reviewed
  • A payment/non-payment determination will be made based on the documentation received, and the claim will be released to continue processing

Back to the top of the page Top

Rights for Unfavorable Exception Requests

If the review of your documentation does not support the exception request, the days impacted by the untimely NOE will process as noncovered. These noncovered days can be appealed by submitting a 1st Level of Appeal – Redetermination.

Back to the top of the page Top

Updated: 04.09.21

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © 2024 CGS Administrators, LLC. All Rights Reserved