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

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.

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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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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.

Hospice and GW Modifier Prepayment Reviews

CGS Medical Review has initiated prepayment review of claims for which the GW modifier is appended to claim line(s). The GW modifier is used to indicate items or services that are not related to the hospice beneficiary's terminal illness or a related condition. The Medicare hospice benefit is administered under Medicare Part A and includes items and services provided to palliate or manage a beneficiary's terminal illnesses and related conditions. Medicare pays the hospice for the DMEPOS items provided to the beneficiaries if the items are necessary part of treatment of their terminal illness or related condition. If it meets this condition, payment is bundled into the hospice's per diem payment.

Suppliers may bill DME MACs separately for an item or service that is not related to the hospice patient's terminal condition. These items or services are indicated on the claim by appending the GW modifier to the claim line. Use of the GW modifier means that the item or service is not related to the hospice patient's terminal condition.

As noted by the Centers for Medicare and Medicaid Services (CMS) and repeated in numerous CMS publications and regulations related to the hospice benefit, payment for items and services separate from the hospice per diem should be "exceptional and unusual" and that hospices are required to "provide virtually all the care that is needed by terminally ill patients."

What are some tips for suppliers who may have claims selected for GW modifier review?

First, you need to maintain close communication with the hospice provider to ensure that the use of the GW is appropriate.

Second, before using the GW modifier, ask the hospice provider to send you their Hospice Election Statement Addendum. You should have this in your files before billing any items with the GW modifier.

The Hospice Election Statement Addendum document, created by CMS in 2020, is designed to provide essential information for patients, their families and caregivers to make informed care decisions and to anticipate any financial liability associated with needed items, services, and drugs not provided under the Medicare hospice benefit.

A complete list of the requirements for this document may be found in the CMS Benefit Policy Manual, Ch. 9, Section 20.2.1.2.

Highlighted below are three of the important points that the hospice is required to list in the Hospice Election Statement Addendum:

The individual's conditions present on hospice admission (or upon plan of care update) and the associated items, services, and drugs not covered by the hospice because they have been determined by the hospice to be unrelated to the terminal illness and related conditions.

A written clinical explanation, in language the individual (or representative) can understand, as to why the identified conditions, items, services, and drugs are considered unrelated to the individual's terminal illness and related conditions and not needed for pain or symptom management.

References to any relevant clinical practice, policy, or coverage guidelines.

The Hospice Election Statement Addendum is an educational document and promotes transparency for the hospice beneficiary, their families or caregivers and any other stakeholders, such as DME suppliers and Medicare Administrative Contractors.

If you use the GW modifier, you should request the Hospice Election Statement Addendum from the hospice provider and have it in your files before using the GW modifier on a claim. CGS will be requesting the Hospice Election Statement Addendum from DME suppliers that use the GW modifier and have claims selected for prepayment review, in addition to medical records to support that the item provided was reasonable and necessary.

How to determine if the beneficiary is in a hospice covered stay? Suppliers can use the myCGS secure web portal to access eligibility information or by using the Interactive Voice Response Unit or IVR. These tools are available 24-hours a day/7-days a week.

Below are helpful resources related to the hospice benefit and the Hospice Election Statement Addendum:

Office of Inspector General Report (A-09-20-03026) – Medicare Improperly Paid Suppliers An Estimated $117 Million Over 4 Years For Durable Medical Equipment, Prosthetics, Orthotics, And Supplies Provided To Hospice Beneficiaries – November 2021: https://oig.hhs.gov/oas/reports/region9/92003026.pdf

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