License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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Claim Payment Alerts

Date Reported

Provider Type Impacted

Reason Codes

Claim Coding Impact

Description of the Issue

Action Required by the MAC

Action Required by the Provider

Proposed Resolution/Fix

Status

Date Resolved

01/23/2023

Suppliers of HCPCS codes that previously required a CMN/DIF form with dates of service on and after 01/01/2023.

Claims for HCPCS that previously required a CMN/DIF.

Claims for HCPCS that previously required a CMN/DIF may have been denied in error for missing the CMN/DIF for dates of service on and after 01/01/2023.

Claims will be adjusted.

No action required.

Additional training was provided to the claims processing staff on these recent changes.

01/23/2023

01/18/2023

Suppliers of Oxygen HCPCS codes submitted with QA, QB, QE, QF, QG, or QR modifiers and HCPCS code K0455 with a date of service on and after 01/01/2023

Oxygen HCPCS codes submitted with modifiers QA, QB, QE, QF, QG, or QR modifiers and HCPCS code K0455

Claims for the HCPCS not hitting the pricing file in the system and are suspending for a price. This may have created a delay in the normal time-frame for payment for claims with a date of service on and after 01/01/2023.

Claims were held awaiting a response to the issue from the Shared System Maintainer.

No action required.

The oxygen and K0455 claims affected have been released. This issue has been corrected.

Resolved

Oxygen modifier issue was resolved on 02/13/2023. K0455 issue was resolved on 03/02/2023.

01/12/2023

Suppliers of HCPCS codes that currently have a CMN/DIF on file with a date of service on and after 01/01/2023.

Claims for HCPCS that currently have a CMN/DIF on file are not processing through the Common Working File correctly.

The Common Working File is rejecting claims back to the contractor looking for a CMN/DIF in error.

Claims are being held until the Common Working File corrects this error.

No action required.

The Common Working File corrected the issue.

Resolved

02/07/2023

01/05/2023

Suppliers of HCPCS codes K0553 or K0554 for claims that were received between 12/16/2022–01/18/2023 with a date service BEFORE 01/01/2023.

K0553 and K0554

The HCPCS codes K0553 and K0554 were terminated incorrectly at the Common Working File. These claims were held by CGS until the Common Working File fixed this error. Once the error was corrected, CGS released these claims for processing. Since claims had to be held, this may have created a delay in the normal timeframe for payment for claims that were received between 12/16/2022–01/18/2023 with a date of service BEFORE 01/01/2023.

Claims were held until the Common Working File corrected the error.

No action required.

The Common Working File corrected the error and all claims have been released for processing.

Resolved

01/18/2023

04/22/2022

Suppliers who have submitted multi-line claims that were processed after 4/1/22

ANSI Reason Code 16; Remark Code MA130

N/A

When a multi-line claim includes line items that are both denied as unprocessable (return/reject) and other lines that are processable, normally the claim is split so the non-return/reject lines will process separately. For claims that processed after 4/1/22, a system issue is causing the processable lines to incorrectly deny with ANSI codes 16/MA130.

The DME MAC is working with the claim system maintainer to correct the issue. We expect a fix to be implemented by the end of April.

Resubmit the claim to resolve the valid unprocessable (return/reject) denial. The previously denied in error lines will then process correctly.

The DME claims process system will be updated to resolve the issue permanently.

Resolved

06/17/2022

06/03/2021

Suppliers of HCPCS codes K0553 or K0554 for claims that were submitted between 05/20/2021–06/02/2021.

K0553 and K0554

Claims for HCPCS code K0553 or K0554 that were submitted between 05/20/2021–06/02/2021 may have denied in error.

Claims received between 05/20/2021–06/02/2021 for HCPCS code K0553 or K0554 that were denied in error as unbundling will be adjusted.

No action required.

Claims will be adjusted if the denial was incorrect.

Resolved

06/29/2022

06/01/2021

Suppliers of HCPCS codes E0651/E0667 that were submitted between 04/01/2021–06/02/2021

E0651 and E0667

Claims for HCPCS code E0651 or E0667 that were submitted between 04/01/2021 to 06/02/2021 may have denied in error.

Claims received between 04/01/2021–06/02/2021 for HCPCS code E0651 or E0667 that were denied in error as not reasonable and necessary will be adjusted.

No action required.

Claims will be adjusted if the denial was incorrect.

Resolved

07/21/2021

12/1/2020

Suppliers whose claims were received between 11/1-11/30/20, were processed between 11/18-12/1/20, with dates of service on or after 9/7/20, which did not include a GW modifier, and were for beneficiaries who elected Hospice.

Multiple codes

Claims processed between 11/18-12/1/20 may have denied erroneously due to the beneficiary electing Hospice. This only applies to claims received between 11/1-11/30/20, with a date of service on or after 9/7/20, and which did not contain a GW modifier.

Claims that denied in error will be adjusted. Editing has been corrected for claims received 12/1/20 and after with a date of service on or after 9/7/20 that are billed without the GW modifier and in which the date of service is within a Hospice election period. Such claims will be denied. Please refer to the article "Billing Reminder GW Modifier" published on 11/16/20.

No Action

Resolved

12/01/2020

10/13/2020

All

ANSI Reason Code: CO-151

ANSI Remark Code: MA01

Multiple

Initial claims were processed against the MUE values incorrectly. This resulted in some initial claim lines allowing zero amounts and amounts should have paid on the claim lines.

Additionally, claim adjustments (including reopening requests, appeal requests, CARES Act adjustments, or any other reasons that a claim would normally be adjusted) that were initiated or in process on 9/23/20 or 9/24/20 have also been impacted. In the case of many of these adjustments, because the initial claim had been paid, the now denied adjustment has automatically created an overpayment situation. You may incorrectly receive overpayment demand letters or immediate offsets regarding these claims.

CGS Action: CGS began adjusting the erroneously denied claim lines on 10/12/2020.

Currently, suppliers do not need to take any action regarding the affected claims, adjustments, or overpayments

All actions (listed below) have been completed by CGS

CGS Action 1: Two phases of adjustments will be necessary to issue correct claim decisions. First, CGS started adjusting claims and suppressing remittance advices on 10/13/2020. The first phase of adjustments will be to return the impacted claims to the appearance of the original claims but not generate remittance advices. The remittances are being suppressed in the first phase because the remittances and claim decisions will not be accurate. The second phase of adjustments will produce the correct remittances and claim decisions.

CGS Action 2: Upon completion of the first phase adjustments, second phase adjustments will be completed on the claims to issue correct decisions and remittance advices.

CGS Action 3: Not all CO-151 denials were processed incorrectly. We recognize it may be difficult to differentiate erroneous denials from valid CO-151 denials and that this may have impacts on timely filing of appeals. For those claims with valid CO-151 denials, CGS will issue new demand letters. The date on the newly issued demand letters will be the date used to determine timely filing of appeals.

CGS Action 4: Suppliers who have overpayments immediately offset and were immediately offset in error, will be issued refunds if no other outstanding debts exist.

Resolved

12/10/2020

09/28/2020

All

151

Multiple

Some claims may have processed against Medically Unlikely Edit (MUE) values incorrectly. The MUE files were incorrect in our system on 9/23/20–9/24/20, affecting claims that were in process on those dates (and continued to affect claims that began processing on those dates, even if the claim completion date was after the file was corrected). Additionally, claim adjustments (including reopening requests, appeal requests, CARES Act adjustments, or any other reasons that a claim would normally be adjusted) that were initiated or in process on 9/23/20 or 9/24/20 have also been impacted. In the case of many of these adjustments, because the initial claim had been paid, the now denied adjustment has automatically created an overpayment situation. You may incorrectly receive overpayment demand letters or immediate offsets regarding these claims. Note that not all CO-151 denials were processed incorrectly.

CGS is working on a solution to resolve this issue as quickly as possible, although we cannot currently provide a timeframe for when all of the claims and adjustments will be corrected.

At this time, you do not need to take any action regarding the affected claims, adjustments, or overpayments.

Please follow this page for updates to this issue.

Claims will be adjusted.

Resolved

12/10/2020

08/27/2020

Suppliers of HCPCS code L8030 with a claim processing date of 08/11/2020–08/28/2020.

107

L8030 (Breast Prosthesis, Silicone or Equal, Without Integral Adhesive)

Claims for HCPCS code L8030 with a processing date of 08/11/2020–08/28/2020 that were denied due to the supplier requiring a license/specialty were denied in error.

Claims processed incorrectly during the span of 08/11/2020–08/28/2020 for HCPCS code L8030 (and any accessory that was on the same claim) will be adjusted by the MAC.

No action required.

Claims will be adjusted.

Resolved

09/30/2020

04/29/2020

Suppliers of HCPCS code J7677

J7677

Claims for HCPCS code J7677 with dates of service from 04/01/2020 to 04/29/2020 may have processed with the incorrect allowed amount.

Claims that were processed with the incorrect allowed amount will be adjusted by the DME MAC.

No action required.

Claims will be adjusted to apply the correct fee.

Resolved

04/29/2020

04/16/2020

All

N/A

Some claims with remittance dates 4/7, 4/14, and 4/21 are remaining open in our system. These claims cannot be adjusted through Reopenings or Redeterminations at this time.

CGS is working diligently with CMS' system maintainer to help resolve the issue.

No action required.

The system maintainer is working to resolve this issue.

Resolved

05/01/2020

04/15/2020

Suppliers of HCPCS codes a4225 who submitted claims that were received by CGS between 03/05/2020–03/31/2020.

151

A4225

Claims for HCPCS code A4225 that were received by CGS between 03/05/2020–03/31/2020 may have processed with the incorrect number of units allowed.

Claims that were processed with the incorrect number of units allowed will be adjusted.

No action required.

Claims are being adjusted by CGS to apply the correct number of units allowed.

Resolved

04/15/2020

03/18/2020

Suppliers of HCPCS codes K0553 with a date of service 02/29/2020 and dates of service 03/01/2020-03/20/2020 that were MAC initiated.

151

K0553

Claims for HCPCS code K0553 with a date of service 02/29/2020 and dates of service 03/01/2020-03/20/2020that may have denied in error for the monthly allowance.

Claims for dates of service 02/29/2020 and dates of service 03/01/2020-03/20/2020 for HCPCS code K0553 that was denied in error for the monthly allowance will be adjusted

No action required.

Claims will be adjusted if the denial was incorrect.

Resolved

09/30/2020

02/01/2019

Suppliers of HCPCS codes E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015 and K0070

E1007, E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015 and K0070

Claims for HCPCS codes E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015 and K0070 may have denied incorrectly due to a system processing issue.

NOTE: This is an ongoing issue with no ETA for resolution.

The issue causing the claim processing error cannot be corrected at this time.

No action required.

A report will be run monthly and claims will be adjusted if the denial was incorrect.

02/01/2019

Suppliers of wheelchair accessories.

151

Wheelchair accessory HCPCS codes.

Claims for wheelchair accessories may have denied as same or similar equipment incorrectly due to a system processing issue.

NOTE: This is an ongoing issue with no ETA for resolution.

The issue causing the claim processing error cannot be corrected at this time.

No action required.

A report is run monthly, and claims are adjusted if the accessories were denied incorrectly.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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