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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.

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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.

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  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.
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Resources for the Most Common Home Health and Hospice Medicare Questions

Listed below are the most common reasons home health and hospice providers contact the CGS Provider Contact Center – Phone number (877) 299-4500 (Option 1).

Please review the list of resources under each topic before contacting the CGS Provider Contact Center for these reasons.

Address/Phone/Fax

  • Home Health & Hospice Contact Information – Interactive Voice Response (IVR) telephone number; IVR User Guide; home health and hospice Provider Contact Center (PCC) telephone number (customer service and Electronic Data Interchange (EDI)); PCC Holiday/Training Schedule; congressional inquiries fax number; mailing addresses to send correspondence, claims, appeals, enrollment information, overpayments, cost reports, and credit balance reports.
  • Other Home Health and Hospice Provider Contact InformationExternal Website (CMS Cost Report Overview webpage) – If you have the other agency's Provider Transaction Access Number (PTAN) or name, use this resource to obtain the, telephone number, and address of the home health agency (HHA) or hospice for assistance in resolving overlapping claim issues.
    • To access home health information, click on "Home Health Agency" and scroll down and click on the "HHA Reports Zip File" link to open a ZIP file, and then select the "HHH_Provider_ID-Info" file to download a spreadsheet containing the contact information for HHAs.
    • To access hospice information, click on "Hospice" and scroll down and click the "Hospice Reports" link, and then select the "hospc_prvdr_id info" file to download a spreadsheet containing the contact information for hospices.
    • National Plan & Provider Enumeration System (NPPES)External Website – Use this resource to obtain contact information to resolve overlapping claim issues.
  • Medicare Advantage (MA) Plan DirectoryExternal Website – Find the contact information for any Medicare Advantage plan in which your beneficiary is enrolled. The MA plan contract number can be found in the "PLAN-ID" field on ELGH page 5 or the PLAN-TYPE field on ELGA page 1. If using the eligibility function in myCGS, the MA Plan's contact information is displayed on the "Plan Coverage" tab. Refer to Chapter 4: Eligibility Tab of the myCGS User Guide for additional information.
  • Helpful Links – Websites that provide wide variety of resources.

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Beneficiary Demographic Information

  • See the "Checking Beneficiary Eligibility " Web page for the options available to determine a beneficiary's demographic information, and instructions for using these resources.

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Calculation or Explanation of Payment

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Claims in a Suspended Status/Location (S/LOC)

  • Suspended claims can be identified in the Fiscal Intermediary Standard System (FISS) by the status code "S" (e.g., S B0100).
  • Generally, providers do not need to take action for claims in a suspended S/LOC. All claims will temporarily suspend in different S/LOCs as they process through FISS.

Below are just some of the common suspended S/LOC codes and what they mean. Refer to the "Fiscal Intermediary Standard System (FISS) Common Locations " Web page for more.

S/LOC Definition Provider Action Needed?
S B0100 System processing No
S B6001 Claim needs additional information from provider (ADR). Yes, a medical review additional development request (ADR) must be received by CGS within 45 calendar days.
S B90XX (XX=denotes a variety of location codes) System is comparing claim data to beneficiary eligibility information posted at the Common Working File (CWF). No
S M0XXX (XXX=denotes a variety of location codes) Suspended claims/adjustments requiring manual intervention by CGS staff. No. Suspended claims/adjustments that require CGS staff intervention may be suspended for about 30 days. Claims with Medicare Secondary Payer (MSP) information may be suspended for more than 60 days. Providers may call the Provider Contact Center if their claim has been in the same "S MXXXX" S/LOC for longer than 30 days, or 60 days for MSP claims.
S MRADJ A Medicare Secondary Payer (MSP) adjustment has been received; claim suspended while awaiting completion. No
S M50MR Medical Review (claim moved to this location once medical documentation has been received.) Please note: the review process may take up to 30 days to complete or 60 days for demand denials. Do not call regarding this status/location unless your claim has been there for more than 60 days. No

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Claims Processing Issues

To report or receive an update about Fiscal Intermediary Standard System (FISS) claims processing issues, check the Claims Processing Issues Log before you call the CGS Provider Contact Center.

Correcting Invalid Information Posted to the Common Working File (CWF)

Please be aware that CGS is unable to update invalid information posted to the beneficiary's eligibility file, including date of death and Medicare Advantage (MA) plan enrollment/termination dates.

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Coverage Issues

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Electronic Data Interchange (EDI)

Please be aware that the CGS Provider Contact Center home health and hospice Customer Service Representatives (CSRs) are unable to assist you with EDI questions related to CMS freeware, billing software, connectivity issues, or resetting your passwords for the Fiscal Intermediary Standard System (FISS) or myCGS.

  • For assistance with security issues with your access to ELGA, ELGH, FISS, or if you need to have your password reset, please email the CGS Security Administration Team at CGS.Medicare.OPID@cgsadmin.com. Be sure to include the user ID that is experiencing problems and the first and last name of the user to which that ID is assigned in your email request. You can also receive assistance with FISS, ELGA, ELGH security issues or password resets by calling 615-660-5444.
  • For all GPNet access and password issues, or password/access issues with myCGS, please continue to call the J15 EDI Helpdesk for assistance at1-877-299-4500 (select Option 2).
  • Refer to the EDI Job Aides for resources on a variety of EDI situations.

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Explanation of Reason Code

After reading through the reason code narrative in FISS, you may be able to access additional information for resolving the billing error from the Top Claim Submission Errors and How to Resolve Webpage. For instructions on reviewing reason code narratives for claims in the Return to Provider (RTP) file, access the Claims Correction (Chapter 5)PDF of the FISS Guide.

Filing/Billing Instructions

Types of billing instructions most requested:

Home Health

Hospice

Medicare Secondary Payer (MSP)

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Missing/Invalid Codes

Most common types of claims that have missing or invalid codes

Adjustments

Home Health

Hospice

Medicare Secondary Payer (MSP)

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Overlapping Benefit Periods, Claims, Episodes, Services

Home Health and Hospice

  • See the "Checking Beneficiary Eligibility " Web page for the options available to determine any overlapping Medicare services that the beneficiary is receiving that may impact your billing. Instructions for using these resources are also available on this web page.
  • Other Provider Contact InformationExternal Website (CMS Cost Report Overview) – If you have the other agency's Provider Transaction Access Number (PTAN), or name, use this resource to obtain the telephone number, and address of the home health agency (HHA) and hospice for assistance in resolving overlapping claim issues.
    • To access home health information, click on "Home Health Agency" and scroll down and click on the "HHA Reports Zip File" link, to open a ZIP file, and then select the "HHH_Provider_ID-Info" file to download a spreadsheet containing the contact information for HHAs.
    • To access hospice information, click on "Hospice" and scroll down and click the "Hospice Reports" link, and then select the "hospc_prvdr_id info" file to download a spreadsheet containing the contact information for hospices.
    • National Plan & Provider Enumeration System (NPPES)External Website – Use this resource to obtain contact information to resolve overlapping claim issues. You will need to click on the link to "Search for an Organizational Provider" to determine the billing agency's contact information.

Home Health

Additional references for overlapping services due to home health beneficiary-elected transfer, or discharge/re-admission during a 60-day episode of care:

If one of the line item dates of service (LIDOS) on your home health claim is overlapping an inpatient stay, access the information about Reason Code C7080 found on the Top Claim Submission Errors (Reason Codes) and How to Resolve Web page. CGS encourages you to use the first Medicare billable visit in the episode as the date of service submitted when billing non-routine or surgical dressing/wound care supplies to avoid errors for overlapping inpatient stays. In addition, please review the information posted to the impact of an Inpatient Admission During an HH PPS Episode Web page.

If your home health claim was adjusted or rejected due to the dates of service overlapping a Medicare Advantage (MA) plan enrollment period, refer to the information about Reason Code U5233 and 7CS21 found on the Top Claim Submission Errors (Reason Codes) and How to Resolve Web page.

If your home health episode overlaps a hospice benefit period and your services are unrelated to the terminal diagnosis, please review the information about Reason Code C7010 found on the Top Claim Submission Errors (Reason Codes) and How to Resolve Web page.

Hospice

Additional references for hospice beneficiary discharge/revocation, or transfer during a benefit period:

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Resolving Rejected Claims

Medicare claims submitted to CGS most often reject due to:

  • Duplicates: a second Medicare claim with the same dates of service for the same beneficiary is submitted by a home health or hospice agency.
  • Eligibility: the claim information submitted by the home health and hospice agency does not match the information posted to the beneficiary's eligibility record at the Common Working File (CWF). For example, a beneficiary has an open Medicare Secondary Payer (MSP) record and the dates of service submitted on the Medicare claim are after the effective date of the record.
    • CGS encourages providers to check a beneficiary's eligibility prior to admission and billing each home health episode or hospice Notice of Election (NOE) or claim to Medicare. For information on accessing, reviewing and understanding the eligibility information available to Medicare providers, see the "Checking Beneficiary Eligibility " Web page.

Depending upon the reason why a claim is rejected, a home health or hospice provider may need to send in a new claim (resubmit), electronically adjust, or send a paper claim adjustment to resolve the original billing error.

Home Health and Hospice Providers

Home Health Providers Only

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Updated: 10.31.23

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