Suppliers that submit claims for HCPCS code J7601 with the KO modifier.

J7601KO

Claims for dates of service 04/01/2025 and after for HCPCS code J7601KO may have processed with the incorrect fee amount when billed as Ohtuvayre® (Ensifentrine).

CGS will reprocess claims that processed with the incorrect drug fee based on the CMS quarterly average sales price (ASP) files.

Errors in claims processing will be corrected, and measures have been put in place to prevent future occurrences.

Suppliers that submit claims for HCPCS codes E1032–E1034 as a purchase with the NU modifier and the item is billed with a complex power wheelchair base submitted as an initial purchase.

E1032NU E1033NU E1034NU

Claims for dates of service 04/01/2025 and after for HCPCS codes E1032NU E1033NU, and E1034NU are denying in error.

The Common Working File (CWF) does not have codes E1032NU E1033NU, or E1034NU included in CWF editing.

CGS will reprocess claims that denied in error with ANSI Remark Code N130: This HCPCS code must be billed as a capped rental unless used with a complex rehab wheelchair. This equipment is only covered when rented.

CMS implemented proactive measures to prevent this denial.

CGS is collaborating with the CWF to put preventative measures in place. Claims that were denied in error will be corrected.

Suppliers who submit claims for HCPCS code Q0511 or Q0512 (supply fee).

Q0511 or Q0512

Claims with a receipt date of 01/01/2025–01/28/2025 with dates of service 01/01/2025–01/28/2025. Claims for HCPCS code Q0511 or Q0512 may have denied in error when billed with Capecitabine (Xeloda).

CGS will reprocess claims that denied in error with ANSI Remark Code 107: This item was denied as non-covered because the related or qualifying claim/service was not identified on the claim.

Claims denied in error will be adjusted and preventive measures have been established.

Suppliers that submit claims for HCPCS code Q0511 or Q0512 for a supply fee billed with Oral Anti-Cancer Drugs or Oral Anti-Emetic Drugs.

Q0511 or Q0512

Claims received 02/21/2025–02/28/2025 for HCPCS Code Q0511 or Q0512 may have denied in error if billed with Oral Anti-Cancer Drugs or Oral Anti-Emetic Drugs.

CGS will reprocess claims that denied in error.

Claims denied in error will be adjusted.

Suppliers who submit claims for Capecitabine (Xeloda) billed with HCPCS code J8999 instead of the appropriate National Drug Code (NDC).

J8999

Claims with a receipt date of 01/01/2025–02/19/2025 with dates of service 01/01/2025–02/19/2025. Claims for HCPCS code J8999 may have processed with the incorrect fee amount when billed as Capecitabine (Xeloda).

CGS will reprocess all claims billed with HCPCS Code J8999 and will convert the HCPCS code to the NDC for dates of service 1/1/2025–2/19/2025. Claim adjudication and payment information will be provided on a remittance advice.

To ensure proper payment, suppliers should reference the February 19, 2025, news article titled Capecitabine Oral Anti-Cancer Drug Billing Instructions.

Claims processed in error will be adjusted and preventive measures have been established.

All DME Suppliers

N/A

Claims with a receipt date of 07/14/2024–09/22/2024 may be denying for incarcerated status when the beneficiary does not have an incarcerated record(s) in the Common Working File (CWF).

CGS will reprocess claims that denied in error with ANSI Remark Code 258: Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state, or local authority may cover the claim/service.

No action needed.

Claims denied in error will be adjusted once the CWF record has been corrected.

Suppliers that submit claims for HCPCS code E2298 as a purchase with the NU modifier and the item is billed with a complex power wheelchair base submitted as an initial purchase.

E2298NU

Claims for dates of service 04/01/2024, and after for HCPCS Code E2298NU are denying in error.

The Common Working File (CWF) does not have code E2298NU included in CWF editing.

CGS will reprocess claims that denied in error with ANSI Remark Code N130: This HCPCS code must be billed as a capped rental unless used with a complex rehab wheelchair. This equipment is only covered when rented.

No action needed.

Claims denied in error will be adjusted and preventative measures have been established.

Until the CWF edit is corrected, code E2298NU will be processed as a miscellaneous code, E1399.

Resolved

07/01/2024

Suppliers that submit claims for HCPCS codes A6530, A6533-A6541, and A6549.

Lymphedema Compression Items. HCPCS codes A6530, A6533-A6541, and A6549.

Claims for dates of service 01/01/2024 and after for HCPCS codes A6530, A6533-A6541, and A6549 are denying in error when three units of service are billed.

CGS will reprocess claims that denied in error.

No action needed.

Editing will be set up to prevent the incorrect denial, and claims denied in error will be adjusted.

Suppliers that submit claims for HCPCS codes A4604, A7030, A7027, A7034, A7037

A4604, A7030, A7027, A7034, A7037

Claims with a date of receipt of 02/14/2024 may have denied in error for over the frequency limits.

CGS will reprocess claims that denied in error.

No action needed.

Editing has been corrected and any claims that denied in error will be adjusted.

Suppliers that submit claims for HCPCS codes A4238 and A4239 where the number of units billed denied because the medical necessity for the quantity has not been established.

A4238 and A4239

Claims for dates of service 01/31/2024 and after for codes A4238 and A4239 are denying in error due to the number of units billed.

CGS will reprocess claims that denied in error with ANSI Remark Code N115: Number of units billed denied because the medical necessity for this quantity has not been established.

No action needed.

Claims denied in error will be adjusted and preventative measures are being established.

Suppliers that submit claims for HCPCS codes A4238 and A4239 with a number of services greater than one.

A4238 and A4239

Claims for dates of service 01/01/2024 and after for codes A4238 and A4239 are denying in error when more than one unit of service is billed.

CGS will reprocess claims that denied in error with ANSI Remark Code MA01 due to Medically Unlikely Edits (MUEs).

No action needed.

Editing will be set up to prevent the incorrect denial and claims denied in error will be adjusted.

Suppliers who submit claims to the DME MAC when the from date of service equals the date of discharge from home health services and the beneficiary is no longer a patient.

Home Health Consolidated Billing for the following: Urological, Ostomy, Tracheostomy, Surgical Supplies.

This issue affects claims with dates of service on and after 01/01/2022 in which the date of service equals the date of discharge from home health services and the beneficiary is no longer a patient. These claims may be denying incorrectly for a home health episode.

Claims with incorrect denials will be adjusted when brought to the DME MACs attention via a redetermination request.

If the denial is incorrect, submit a redetermination for correction.

Editing will be corrected at the Common Working File, (CWF) to prevent the incorrect denials and recoupments.

Suppliers of Lower Limb Prosthetic HCPCS with claims received 10/02/2023-10/04/2023 for Jurisdiction C.

4 & N519

Lower Limb Prosthetic HCPCS, L5000-L5999

Claims may have rejected in error based on modifiers.

Claims are being researched.

No action necessary.

CGS will identify the affected claims and re-process if incorrectly denied.

Prior Authorization wheelchair bases and voluntary wheelchair accessories with dates of service on and after 04/06/2023.

ANSI Reason Code 39; Remark Code N210 & ANSI Reason Code 16; Remark Code MA66

Prior Authorization wheelchair bases and voluntary wheelchair accessories.

If there is a non-affirmed accessory code on the claim and the base and/or other accessories are affirmed, claim lines may reject/deny in error.

CGS will reprocess claims that denied in error.

No action required.

Suppliers of capped rental equipment that submitted EMC claims with KH or KI modifier on 05/31/23 (CCNs starting 23151).

182

Capped Rental HCPCS with KH or KI modifier

Claims for capped rental equipment submitted by EMC on 5/31/23 (CCNs starting 23151) were possibly denied in error with ANSI Reason Code 182; Remark Code N517 when submitted with the KH or KI modifiers.

CGS will re-process claims that denied in error.

If you received an incorrect denial, please delay submission of the next month's rental until this issue is resolved.

CGS will re-process claims that denied in error.

Suppliers of Prior Authorization Voluntary Wheelchair Accessory HCPCS codes with dates of service on and after 04/06/2023.

16 & 284

Voluntary Prior Authorization Wheelchair Accessory Codes

Claims may reject if the Unique Tracking Number (UTN) is submitted on claim lines that were not submitted for a Prior Authorization.

CGS will re-process claims that denied in error.

Submit the UTN only on claim lines for Voluntary PA items for which a Prior Authorization was requested. The UTN should be submitted in loop 2400 – Service Line loop in the Prior Authorization reference (REF) segment where REF01 = "G1" qualifier and REF02 = UTN.

CGS is working with the system maintainers for resolution.

Suppliers of oxygen HCPCS codes with initial dates of service on and after 04/01/2023 and a date of receipt 04/01/2023-04/25/2023

N/A

Oxygen HCPCS codes

Modifiers N1, N2, N3 were valid for use on oxygen HCPCS codes for initial dates of service on and after 04/01/2023. If the N1, N2, N3 modifier was included on the HCPCS and the initial date of service is on and after 04/01/2023 with a receipt date of 04/01/2023-04/25/2023 the claim line may have denied in error as unprocessable.

Claims will be corrected.

No action required.

Editing has been updated for the new modifiers.

Suppliers who have submitted claims for HCPCs code Q2052 (services, supplies and accessories used in the home under the Medicare intravenous immune globulin (IVIG) demonstration) that were affected by the payment rate calculation in alignment with the national per-visit payment amount for home health agencies (HHA). Refer to MLN Fact Sheet MLN3191958.

N/A

Q2052

Per CMS direction, claims for HCPCS Code Q2052 for dates of service 01/01/2022–04/04/2023 will be adjusted with the new payment rate.

Claims will be adjusted.

No action required.

Claims will be adjusted by 05/19/2023.

Suppliers that submit claims for HCPCS Code E2394 with a number of services greater than one.

151

E2394

Per CMS direction, claims for HCPCS Code E2394 for dates of service 01/01/2023-06/30/2023 that have a number of services greater than one will be held until the Medically Unlikely File has been corrected.

Claims will be held for current claims. For previously denied claims, adjustments will be initiated after the file has been corrected (July 2023).

No action required; however, suppliers may choose to delay submission of claims for this code until after July 1, 2023, retroactive date.

The Medically Unlikely File will be corrected.

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

16

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.

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

NA

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.

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

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

NA

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.

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.

NA

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.

Suppliers who have submitted claims that were affected by the correction of the 2022 DMEPOS Fee Schedule amounts for certain items furnished in non-contiguous areas (Alaska, Hawaii, Puerto Rico, and U.S. Virgin Islands).

N/A

N/A

Claims for specific HCPCs codes in non-contiguous areas 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 by December 5, 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.

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

97

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.

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

50

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.

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.

B9

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

NA

All

ANSI Reason Code: CO-151

ANSI Remark Code: MA01

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). This resulted in two issues.

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.

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.

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.

Suppliers of HCPCS code J7677

45

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.

All

N/A

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.

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.

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.