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.

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

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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.
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 website.
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Frequently Asked Questions (FAQs)

Current FAQs from Customer Support

Click on a question to expand or Show All / Close All

I need to find out if a beneficiary has had a specific item in the past (same or similar inquiry). What's the best way to find this information?
- The best way to obtain same or similar information is through the myCGS DME MAC web portal. The Same/Similar screen allows you to view a complete picture of a beneficiary's prior equipment history for a specific product category, including orthotics and prosthetics. You can also search by HCPCS code, partial HCPCS, or a range of codes. The myCGS User Manual explains how to use the Same/Similar search feature.
  
  Same or similar information is available for some products in the Jurisdiction B IVR. The IVR will report the following information if there is same or similar equipment on file:
  - Whether or not a CMN/DME information form (DIF) is on file, including the HCPCS code.
  - CMN/DIF initial date, revised date, and/or recertification date
  - Length of need
  - Number of months paid (if rented)
  - Last paid date (if rented)
  - Phone number of previous supplier (if rented)
  Note: Customer service representatives (CSRs) are unable to release any extra information outside of what the IVR can provide.
  
  Same or similar information for orthotics/prosthetics (L codes) is only available through myCGS or by written inquiry. CSRs are not able to give claim history for orthotics/prosthetics.
  
  Published: 11.08.13
  Revised: 06.07.24
How can I figure out if a beneficiary enrolled in a Medicare Advantage Plan (MAP)?
- The easiest way to obtain Medicare Advantage Plan (MAP) information is through the myCGS DME MAC web portal. The Beneficiary Information tab shows detailed MAP information including historic information in a 16-month span.
  
  You can obtain MAP enrollment effective dates, name, and contract ID through the Jurisdiction B IVR. Press option 1 (Beneficiary Information) from the main menu, then option 1 (Beneficiary Eligibility) and follow the prompts. A list of names, addresses, and phone numbers for MAP contractors is on the CMS website.
  
  Published: 11.08.13
  Revised: 06.07.24
Where can I find guidance on filing a claim?
- Chapters 6 and 8 of the DME MAC Supplier Manual includes rules for mandatory claim submission, assignment, time limit, place of service, claim completion instructions, and much more.
  
  Our Provider Outreach and Education (POE) team offers education on claim submission and other important topics. The POE calendar of events, online education courses, videos and other information is available on the Education and Outreach page.
  
  Published: 11.08.13
  Revised: 06.07.24
How do I check the status of my claim?
- CMS requires the use self-service technology to obtain claim status and beneficiary eligibility information. Customer Service Representatives are not able to provide it.
  
  CGS offers two self-service methods to check the status of a claim: through the myCGS Web portal or by calling the Interactive Voice Response (IVR) line. The myCGS web portal is the easiest way to obtain claim status information, and much more. We have resources on the myCGS DME MAC Web Portal page to help you learn more.
  
  Suppliers may also use claim status inquiry (CSI) through a gateway connection with a network service vendor.
  
  Published: 12.14.22
  Revised: 06.07.24
What if my claim status is not on file?
- Only claims processed by DME MAC Jurisdictions B or C are available on the myCGS DME MAC web portal. Only claims processed by DME MAC Jurisdiction B are available on the JB Interactive Voice Response (IVR) line. Consider the following questions:
  - Is the claim for durable medical equipment, prosthetics, orthotics, or supplies? If it is not for DMEPOS items, then it is possible the provider needs to check a different part of Medicare, like Part B. Supplier Manual Chapter 1 - Introduction explains the different parts of Medicare.
  - What jurisdiction is the beneficiary's address in? The beneficiary’s address on file with the Social Security Administration decides the claim jurisdiction. Send DMEPOS claims to the DME MAC jurisdiction for the state in which the beneficiary lives. Supplier Manual Chapter 15 – Resources lists four DME MAC jurisdictions with states and territories.
  - What jurisdiction should the claim be in? The beneficiary may receive DME in a state different from their address on file.
  - Was the claim sent on paper or electronically? If it is a paper claim, we may not have received it or we may have rejected it. We publish claim submission guidelines in the Supplier Manual Chapter 6 - Claim Submission and Supplier Manual Chapter 8 – EDI.
    
    If you filed the claim electronically, check with your software vendor, billing service or clearinghouse, if applicable. The CEDI (Common Electronic Data Interchange) contractor publishes information on the CEDI Contractor website about electronic claim front end edits and reports.
  Published: 12.14.22
  Revised: 06.07.24
Where can I get information related to a specific offset of an overpayment?
- You can find information about specific offsets using either the myCGS web portal or the Jurisdiction B IVR.
  
  To find offset information in myCGS, log in to myCGS, go to the Finance tab, and select the Offsets secondary tab. After entering the financial control number (FCN) of the offset from your Remittance Advice, myCGS will provide you with the original overpayment date, current offset balance (if any), name and MBI of the beneficiary on the original overpayment, and the overpaid date of service.
  
  To obtain offset information from the IVR, press option 3 for Payment Information and 3 again for Offset Information. The IVR will ask you for your NPI, PTAN, last 5 digits of your tax identification number (TIN), and the FCN from your Remittance Advice. The IVR will provide you with the claim details of the original overpayment, as well as the overpayment letter date and current offset balance.
  
  If the overpayment was from a PTAN associated with the same Tax ID, starting April 1, 2024, the Remittance Advice includes the PTAN of the location that caused the withheld amount. See Provider Level Adjustment Codes on Remittance Advice for details.
  
  Published: 11.08.13
  Revised: 06.07.24
We received a Remittance Advise with ANSI Reason Code 45. How was the allowed amount calculated on my claim?
- The item paid at the greatest amount allowed for the HCPCS code you billed. For more information about pricing, see the Supplier Manual Chapter Ten – Pricing. If you disagree with the decision, request a redetermination.
  
  Published: 06.14.24
What if I receive a same/similar denial?
- Check out the following resources:
  - If the item denied with ANSI Reason Code M3 – Supplier Manual Chapter 3, Section 13 explains how liability is assessed on same or similar denials.
  - Repairs, maintenance, replacements, and reasonable useful lifetime (RUL) – Supplier Manual Chapter 3, Section 11 and Chapter 5, Section 9
  - Same/Similar Code Lookup Tool – enter a HCPCS code in the search field to view a list of other HCPCS codes that may be the same as or similar to the base item entered.
  Published: 12.30.22
  Revised: 06.07.24
I received a medical necessity denial. What should I do next?
- Refer to the appropriate Local Coverage Determination (LCD) and Policy Article. You can also consider these questions:
  - Does the item require a modifier?
  - Does the item require a specific diagnosis?
  - Did you receive a development letter?
  If you disagree with the decision, consider submitting a redetermination request.
  
  Published: 12.30.22
  Reviewed: 06.07.24
Our claim denied as a misrouted claim, claim/service not covered by this payer/contractor. Who is the correct payer/contractor?
- The claim could have denied for one of these reasons:
  1. The beneficiary record on file shows an address in a different DME MAC jurisdiction. You must submit DMEPOS claims to the DME MAC jurisdiction where the beneficiary lives according to current records. See current maps and lists of MACs.
  2. The beneficiary enrolled in a Medicare Advantage Plan (MAP). Submit the claim to the MAP instead of the DME MAC (fee-for-service Medicare).
  Published: 06.14.24
How do we correct claims that denied with Remittance Advice Remark Codes N256 and N257, Missing/incomplete/invalid billing provider number?
- Your supplier number (PTAN) was revoked. If you believe your PTAN was revoked in error, contact the National Provider Enrollment (NPE) contractor. Resubmit the claim after the NPE has corrected and updated your PTAN.
  
  If you disagree with the claim decision, submit a redetermination request.
  
  Published: 06.14.24
How do we correct claims that denied with Remittance Advice Remark Code N570, Missing/incomplete/invalid credentialing data?
- There are three reasons your claim may have denied for this reason:
  1. Our records show that your supplier number (PTAN) was not certified/eligible on this date of service. All DMEPOS suppliers must be accredited by a CMS-approved accreditation organization to receive payment from the DME MAC. Refer to the Supplier Standards listed in the Supplier Manual, Chapter 2. If you were certified/eligible on this date of service, contact the National Provider Enrollment (NPE) contractor to have your information corrected. Resubmit the claim after the NPE has corrected and updated the record.
  2. Our records show that your PTAN was not effective for the date of service billed. Check to make sure you billed using the correct NPI. If the NPI was incorrect, resubmit the claim with the correct NPI. If the NPI billed was correct, contact the National Provider Enrollment (NPE) contractor to determine why your PTAN is not effective. Resubmit the claim after the NPE has corrected and updated the record. If you disagree with the claim decision, submit a redetermination request.
  3. You are not eligible to receive Medicare payment. Check to make sure you billed using the correct NPI. If the NPI was incorrect, resubmit the claim with the correct NPI. If the NPI billed was correct, contact the National Provider Enrollment (NPE) contractor to determine if there is an issue with your PTAN. If you disagree with the claim decision, submit a redetermination request.
  Published: 06.14.24
How can I check the status of my Redetermination request?
- You can check the status of a redetermination by using the myCGS web portal or the Jurisdiction B IVR.
  
  In myCGS, go to the Reprocessing tab. You can search for a Redetermination by either the document control number (DCN) of the case or the claim control number (CCN) of the claim. myCGS will then provide you with the date in which we received your request and the status of the case, including whether it is pending, reversed, upheld, or dismissed.
  
  To find Redetermination status on the IVR, select option 2 (claim information), followed by option 3 (Redetermination information), and then option 2 (Redetermination status).
  
  To verify Redetermination status, you must enter your NPI, PTAN, last five digits of your tax identification number (TIN), the beneficiary's Medicare number, beneficiary's name, and the claim number (CCN, ICN) of the appealed claim. The IVR will give the status of your Redetermination request, including whether it is pending, reversed, upheld, or dismissed.
  
  Published: 11.08.13
  Revised: 06.07.24
What are the top Targeted, Probe and Educate (TPE) reasons for denial?
- We publish Medical Review Quarterly Reports for items under pre-payment review. Each report shows the top 10 reasons for claim denials for the policy or topic under review.
  
  Published: 12.14.22
  Revised: 06.07.24
Can the Standard Written Order (SWO) list multiple types of CPAP and RAD supplies and accessories such as masks, cushions, pillows, tubing?
- Yes. It is acceptable to use a generic description of each type of item ordered. For example, CPAP mask to fit, CPAP mask interface, CPAP tubing. It is also acceptable to list all potential CPAP/RAD supplies on the SWO. However, it is not acceptable to only write “CPAP Supplies” on the SWO. You must list each item that will be separately billed.
  
  Published: 04.15.24
  Revised: 06.07.24
What is the status of my prior authorization request?
- myCGS web portal is the quickest method to find the status of your prior authorization request. You can also view and print the decision letter in myCGS. CGS will also send the decision letter to you in the mail.
  
  Published: 06.14.24
Can a prior authorization decision be transferred to another supplier?
- Yes. The prior authorization decision and Unique Tracking Number (UTN) stays with the beneficiary. A supplier may transfer the UTN to another supplier per applicable privacy laws Click here for more information about the prior authorization process.
  
  Published: 03.21.24
  Revised: 06.07.24
Where can I find phone numbers and addresses for CGS and other Medicare contractors?
- We list addresses and phone numbers for CGS and other Medicare contractors here: Contact Information.
  
  You can also find contact information for other DME MACs, and other Jurisdiction B resources, by referring to the DME MAC Supplier Manual, Chapter 15.
  
  CMS publishes current maps and lists of Medicare Administrative Contractors here: Who are the MACs.
  
  Published: 11.06.23
  Revised: 06.07.24
How do I use this website?
- We recorded a special video to show how to use our website. Watch the CGS Website Tutorial to learn how to navigate, find provider education materials, locate information, and understand different features.
  
  Published: 12.14.22
  Revised: 06.07.24
How do I know when there are system issues with the myCGS DME Web Portal?
- Look for the button at the top right-hand corner of the CGS website, below the "Join Electronic Mailing List" link and just above the search bar. It is present on every CGS webpage.
  
  The button's color shows the myCGS status:
  - Green – myCGS is functioning normally.
  - Yellow – there is an issue with one of the myCGS features.
  - Red – myCGS is currently down.
  If you click on the myCGS Status button, you'll go to the myCGS Alerts page, which lists the myCGS Status button key and current and past myCGS issues and their statuses.
  
  Published: 06.14.24