LICENSES AND NOTICES

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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July 13, 2020

Understanding Claim Denials

CGS provides suppliers with resources to better understand claim denials and what causes them. Claims processed by the DME MACs contain Remittance Advice Remark Codes (RARCs) and Claim Adjustment Reason Codes (CARCs) that provide additional clarification on the completed claim. In some cases, only generic information is provided for the code(s). Suppliers are encouraged to use the resources available to determine the specific reason for the denial.

There are numerous self-service tools to assist suppliers in obtaining information on non-complex issues, therefore; omitting the need to contact a customer service representative. Below are some of the self-service tools available on our website which provide information to suppliers with understanding claim denials.

  • myCGS web portal
  • Online Tools & Calculators
  • Webinars
  • Online Education Courses (OECs)
  • Supplier Manual

Suppliers can also find the Remittance Advice Resources and FAQsExternal PDF booklet on the CMS website for additional information about understanding the remittance.

The RARCs and CARCs used in claims processing are standardized codes that were adopted by Medicare based on the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This Act instructs health plans to conduct standard electronic transactions under HIPAA using valid standard codes. Medicare policy states that RARCs are required on the remittance advice and coordination of benefits transactions and the CARCs are required on the remittance advice. The RARC and CARC lists are updated three times a year. Suppliers can find the most current version of the RARCs and CARCs on the Washington Publishing Company's (WPC) websiteExternal Website.

Here are some of the top denial reasons. Also included with the denial reason is information you may see, that is intended to explain how the claim was processed. Refer to the remittance advice and/or myCGS for the exact verbiage and explanation.

  • Same/Similar item: The item is the same or similar to equipment already being used or in the beneficiary's possession.
    • Example: Billing for K0003 and the beneficiary has a K0001 on file.
      • Use myCGS to verify the type of equipment owned or in use by the beneficiary.
  • Maximum allowable for the HCPCS: Per the LCD/Policy Article, the maximum number of services/units have been allowed for this beneficiary for this code.
    • Example: One pair of depth shoes (A5500) paid within the calendar year. A second pair billed within the same timeframe exceeds the maximum allowance for the code.
      • Verify the maximum number services allowed per the specific LCD/Policy Article.
  • The number of units billed is denied because the medical necessity does not support the number of items billed within the timeframe.
    • Example: Billing four latex leg bags per month whereas the policy only allows for one during that time period.
      • Verify the number of units available per the LCD/Policy Article or Medically Unlikely Edits (MUEs) for the HPCPCS code.
  • The medical necessity for the item was not established.
    • Example: Billing for enteral nutrition for a beneficiary without documentation of a feeding tube in place.
      • Refer to the LCD/Policy Article for coverage criteria.
  • Our records show the beneficiary was in a hospital or skilled nursing facility on the date of service.
    • Example: Date of service for DME 04/03/2020 but the beneficiary was listed as inpatient hospital until 04/05/2020.
      • Check the myCGS web portal or the IVR for SNF/Hospital stay information.
  • The beneficiary's address on file is outside the DME MAC's jurisdiction billed.
    • Example: Claim filed to Jurisdiction C but the Social Security Administration shows the beneficiary's address located in Jurisdiction A.
      • Verify beneficiary information in myCGS to obtain the correct Jurisdiction location.
  • CMN/DIF required or missing.
    • Example: Claim billed for enteral nutrition but the DIF was not received or the one on file expired.
      • The LCD/Policy Article lists CMN/DIF requirements, if applicable.
  • Modifier missing or inconsistent with the HCPCS code billed.
    • Example: Surgical dressing codes billed without modifiers to indicate the number of wounds or if the coverage criteria was met.
      • Use the Advanced Modifier Engine (AME) to verify modifier usage or check the LCD/Policy Article.

Visit the CGS website for additional information on resources to assist with the claim submission process. The appropriate links are listed below:

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