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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.

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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Medical Review Additional Development Request (ADR) Process Postpayment Review

WHAT IS AN MR ADR? – When a claim is selected for medical review, a medical review additional development request (MR ADR) is generated requesting medical documentation be submitted to ensure payment is appropriate. Documentation must be received by CGS within 45 calendar days for review and payment determination.

WHY AN MR ADR? – Any claim submitted to CGS may be selected for medical review and generate an MR ADR. Claims may be selected when elements on the claim match the parameters of a postpayment edit established by CGS. A current list of postpayment edits can be accessed from the Home Health and Hospice Medical Review Activity Log Web page.

The information below will help ensure that necessary steps are taken to submit documentation timely and avoid having claims denied as a result the MR ADR process.

CHECKING FOR MR ADRs

United States Postal Service (USPS)

Requests for additional documentation are mailed to the agency mailing address on file in FISS. Please ensure FISS is up to date with accurate mailing address information and the process for routing the ADR request to the person(s) responsible for submission is timely and effective. Inform your staff responsible for receiving the ADR letter and submitting the required documentation for review. Please include the letter with the documentation that you send for review.  Authorization for the release of the information is included in Federal Law regulations reference 42 CFR 411.24(a), 424.5(a)(6) and 44 USC 3101.

Electronic Submission of Medical Documentation (esMD)

For more information on the esMD process, refer to the CGS "Electronic Submission of Medical Documentation" and Electronic Submission of Medical Documentation (esMD) OverviewExternal WebsiteWeb pages.

PREPARING YOUR DOCUMENTATION

When preparing your documentation, submit a copy of the ADR request and cover sheet with each appropriate ICN/DCN to separate applicable documentation for review.

If you are responding to multiple MR ADR requests, clearly separate the documentation for each claim. Due to CGS's process for imaging documentation, the use of rubber bands or binder clips, or mailing documentation for each claim in separate envelopes, is recommended. Multiple responses sent together, but not separated, may result in the documentation being imaged as one claim. Do not staple documentation.

CGS recommends providers organize the medical documentation in the order indicated below. This will assist CGS in reviewing your documentation more efficiently and will expedite the review process.

Providers should submit the necessary documentation to support the services for the billing period being reviewed. This may include documentation that is prior to the review period, such as admission records, hospice Interdisciplinary Group (IDG) review, etc.

Hospice ADR Checklist – Preferred Order

Home Health ADR Checklist – Preferred Order

  1. ADR Request and Cover Sheet
  1. ADR Request and Cover Sheet
  1. Signed election statement
  1. Physician Face-to-Face documentation
    1. Actual encounter note or progress note
    2. Discharge summary from inpatient stay
  1. Plan of care with physician certification/recertifications
  1. Plan of care with physician certification/recertifications
    1. If recertification, include initial certification
  1. Physician Face-to-Face documentation (for third and later benefit periods)
  1. Interim/verbal orders
  1. Physician orders
  1. OASIS assessment
  1. IDG reviews/POC updates

    Note: include reviews for each 15-day period to cover the billing period. This may include reviews/updates that occurred prior to the billing period.

  1. Nursing visit notes
  1. Admission initial assessment
  1. Therapy visit notes including evaluations/re-evaluations
  1. Visit notes (nursing, social worker, chaplain, etc.)
  1. Social work visit notes
  1. Physician visit notes
  1. Aide visit notes
  1. Other relevant documentation
  1. Other relevant documentation
    1. Acute/post-acute care documentation to support home health eligibility.

Providers may include an outline or cover letter with their documentation. This can be used by CGS Medical Review staff as a roadmap and prove very helpful to highlight key dates or documentation that supports payment of the claim. However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter in order to be useful.

In addition, providers may use brackets, such as [ ] or { }, asterisks (*) or underlined text in the documentation to draw the reviewer's attention to important information. However, notations should not alter, or give the appearance of altering, the documentation. The use of a highlighter is not recommended.

SUBMITTING YOUR DOCUMENTATION

Documentation may be received by CGS either via US Mail, esMD, Fax, myCGS or on CD/DVD.

Submit your documentation so that it is received by CGS on/before 45 days, specific date is provided in the ADR Notice Letter. Ensure that you allow ample time for mailing, and processing of the documentation when received. This will prevent the claim from inadvertently denying. Mail to the address that appears in the ADR Notice Letter:

J15-HHH Correspondence
CGS Administrators, LLC
PO Box 20014
Nashville, TN 37202

NOTE: CGS does not recommend sending your documentation overnight via Fed Ex or UPS. If prompt mailing of your documentation is necessary to meet the due date, CGS recommends overnight delivery via the US Postal Service to the address above. Using myCGS to submit your documentation is also an option.

myCGS is a free web portal that allows you to submit your ADR documentation directly to CGS and will help to ensure a timely response to an MR ADR. For more information on submitting MR ADR documentation via myCGS, refer to the myCGS User Manual: Forms information and the myCGS MR ADR Job Aid. myCGS also provides a secure message confirming receipt of the documentation, and a second message confirming it was accepted.

The Electronic Submission of Medical Documentation (esMD) process may be used as an alternative to mailing your documentation. For more information on the esMD process, refer to the CGS "Electronic Submission of Medical Documentation" Web page.

CGS will also accept documentation submitted via Fax (1.615.660.5981).

RECEIPT OF DOCUMENTATION – Providers may monitor receipt of documentation by CGS through the delivery method selected (e.g. USPS proof of delivery signature record, fax transmission verification report).

REVIEW OF DOCUMENTATION – A CGS nurse reviewer will examine the medical records submitted to ensure the technical components (OASIS, certifications, election statement, etc.) are met, and that medical necessity is supported. CGS has 60 days from the date the documentation is received to review the documentation and make a payment determination.

A hierarchy is used to review documentation. This means that documentation is first reviewed for administrative documentation, and then medical documentation. Denials are applied according to the hierarchy; however, any additional findings will be addressed in the medical review findings notification.

Hospice Hierarchy   Home Health Hierarchy
Valid election statement Technical components: OASIS submission, certification/orders, FTF
Technical components: certification statement, FTF if 3rd or later benefit period Homebound documentation
POC updated every 15 days Intermittent skilled nursing or therapies
Disease acuity or trajectory supports 6 month prognosis – Hospice LCD: "Determining Terminal StatusExternal Website" Reasonable and medically necessary skilled service
Non-routine care supported Use "Physical Therapy – Home HealthExternal Website" LCD for guidance (when applicable)
Physician visits OASIS and coding

ADR OUTCOMES – Possible outcomes of the MR ADR include affirmation of the original payment in full or denial of the payment (in part or in full). If any part of the claim is denied, an overpayment is assessed, and funds are recouped from the provider. The final demand letter will be sent by Overpayment recovery. When a claim is denied with reason code 56900 indicating that the medical documentation was not received by CGS, or was not received timely, a "56900 reopening" may be requested within 120 days of denial to have the medical documentation reviewed by the Medical Review department, without utilizing the Medicare Appeals Process. All other denials for which the provider disagrees may be appealed using the Medicare Appeals Process.

ADR RESOURCES

Updated: 06.08.21

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