J15 Part A Resolved Issues
Updated: 09.26.24
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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07.09.2024 |
Closed |
Part A |
July 2024 remits are currently unavailable. | N/A | 07.17.2024 |
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Updates |
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MAC Action |
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Provider Action |
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Proposed Resolution |
We are working quickly to restore them for you. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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04.23.2024 |
Closed |
Outpatient claims |
An incorrect status indicator assigned to outpatient claims with a line-item date of service on or after 1.1.2024 and CPT code 0621T or HCPCS code J7353. |
LIDOS on or after 1.1.2024 and CPT code 0621T or HCPCS code J7353 | 07.01.2024 |
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Updates |
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MAC Action |
CGS will:
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Provider Action |
N/A |
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Proposed Resolution |
CMS will correct errors to codes 0621T, J7353 and C9167 in the July 2024 Hospital Outpatient Prospective Payment System update. See the MLN Connects Newsletter: April 25, 2024, for details. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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02.21.2024 |
Closed |
Outpatient claims |
Reason Code W7092: Effective January 1, 2024, outpatient claims submitted with certain procedure codes returned to provider (RTP’d) for missing a device code in error. |
W7092 |
HCPCS codes C1052, C1062, C1734, C1824, C1825, C1839, C1982 and C2596 |
04.01.2024 |
Updates |
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MAC Action |
CGS will suspend claims to status/location (S/LOC) S M7092 to apply a workaround until the system update is implemented (scheduled in April 2024). |
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Provider Action |
You may F9/resubmit any RTP claims you identify for CGS to apply the workaround. |
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Proposed Resolution |
A system update is scheduled with the April 2024 release. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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02.08.2024 |
Closed |
Outpatient claims |
Claims submitted with HCPCS codes G2066, 93297 or 93298 will return to provider (RTP) until a system correction is installed. |
HCPCS codes G2066, 93297 or 93298 |
04.01.2024 |
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Updates |
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MAC Action |
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Provider Action |
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Proposed Resolution |
Effective, January 1, 2024, claims for these services will RTP due to the following:
A system correction is scheduled for the April 2024 release. Once installed, CPT codes 93297 and 93298 will assign to a separately payable status indicator (Q1) and APC 5741, effective January 1, 2024. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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11.06.2023 |
Closed |
Ambulance |
Beginning on 10.02.2023, FISS did not retain the fractional units on Direct Data Entry (DDE) claims with ambulance mileage services. |
32226 |
DDE claims with TOB 13X or 85X and ambulance mileage services |
11.27.2023 |
Updates |
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MAC Action |
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Provider Action |
You may F9/resubmit any claims that received reason code 32226 in error. |
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Proposed Resolution |
11.27.2023 – A system correction was installed. A system correction is tentatively scheduled. We will provide updates when available. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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08.07.2023 |
Closed |
Non-OPPS claims |
Non-OPPS claims returned to provider (RTP'd) with reason code W7048 in error. |
W7048 |
Claims received on or after July 1, 2023 |
01.02.2024 |
Updates |
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MAC Action |
CGS will override reason code W7048 until the system update is implemented in January 2024. |
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Provider Action |
You may F9/resubmit claims that RTP'd in error. |
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Proposed Resolution |
01.02.2024 – A system correction was installed. A system update is scheduled with the January 2024 release. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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08.02.2023 |
Closed |
TOBs 22X, 23X and 85X |
Certain outpatient rehabilitation claims returned to provider (RTP'd) with reason code W7072 in error. |
W7072 |
Claims submitted between January 1 – June 30, 2023 Revenue codes 042X, 043X or 044X CPT codes 98980 and/or 98981 |
07.03.2023 |
Updates |
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MAC Action |
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Provider Action |
You may F9/resubmit claims that RTP'd in error. |
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Proposed Resolution |
A system update was implemented with the July 2023 quarterly release. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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07.03.2023 |
Closed |
Various Outpatient TOBs |
Some claims for audiologists who furnished certain diagnostic tests without a physician order returned to provider (RTP'd) in error. |
34963 |
Claims received on or after April 1, 2023, with modifier AB on all lines |
01.02.2024 |
Updates |
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MAC Action |
When all lines on the claim contain modifier AB, CGS will override reason code 34963 until the system update is implemented in January 2024. |
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Provider Action |
Review claims that received reason code 34963.
NOTE: An audiologist is not a valid attending provider. Please reference the CMS MLN Matters articles MM12889 (reason code 34963) and MM13055 (modifier AB) for additional information. |
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Proposed Resolution |
01.02.2024 – A system correction was installed. A system update is scheduled with the January 2024 quarterly release. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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06.29.2023 |
Closed |
ESRD |
Due to a coding error, certain beneficiary records in the Common Working File (CWF) reflected an incorrect initial date of first dialysis (e.g., ESRD eligibility date or first of the month when the date of first dialysis occurred after the eligibility date). As a result, the onset payment adjustment for new ESRD beneficiaries did not apply to some ESRD claims correctly. |
N/A |
TOB 72X; |
09.29.2023 |
Updates |
09.22.2023 – Another refresh was completed to ensure all affected beneficiary records are correct. See the Provider Action and MAC Action sections below. 07.18.2023 – The refresh mentioned in the Proposed Resolution section below did not update all affected beneficiary records. CMS is still researching, and we will provide updates when they become available. |
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MAC Action |
CGS will adjust affected ESRD claims within 120 days of a provider’s request. See Provider Action below. |
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Provider Action |
If you identify a claim that meets the criteria above, you may submit a claim adjustment (TOB 727) to correct the claim payment. Please indicate “ESRD Onset Adjustment Correction” in the Remarks field. |
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Proposed Resolution |
The coding error was corrected on June 12, 2023, and a refresh of beneficiary records was completed in the CWF on June 13, 2023. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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06.15.2023 |
Closed |
RHC |
RHC claims paid under the all-inclusive rate (AIR) and billed with modifier CG may have processed with coinsurance in error. |
N/A |
TOB 71X |
07.31.2023 |
Updates |
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MAC Action |
Claim adjustments occurred on 7.31.2023. |
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Provider Action |
N/A |
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Proposed Resolution |
The system logic was corrected on 6.12.2023. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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10.13.2022 |
Closed |
OPPS Hospitals |
On September 28, 2022, the United States District Court for the District of Columbia vacated the differential payment rates for 340B-acquired drugs in the Calendar Year 2022 Outpatient Prospective Payment System (OPPS) final rule with respect to their prospective application. |
N/A |
OPPS claims for drugs reported with modifier JG and a line item date of service in calendar year 2022 |
11.09.2022 |
Updates |
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MAC Action |
Per CMS instructions, CGS will adjust/reprocess claims that paid on 09.28.2022 through 09.30.2022. |
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Provider Action |
You may adjust (TOB XX7) impacted claims that paid prior to 09.28.2022. Report condition code D9 and "340B reprocessing" in Remarks. NOTE: Timely filing rules (i.e., one calendar year from the "through" date of service) apply. | |||||
Proposed Resolution |
CMS instructed us to upload revised OPPS drug files that will apply the default rate (generally ASP plus 6%) to 340B-acquired drugs for the rest of the year. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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04.29.2022 |
Closed |
Outpatient |
Non-roster claims submitted with a COVID-19 vaccine and another vaccine (e.g., flu or pneumonia) on the same date of service returned to the provider (RTP'd) with reason code 32287 in error. |
32287 |
Non-roster claims received prior to 10.1.2022 with a COVID-19 vaccine and another vaccine on the same date of service |
10.03.2022 |
Updates |
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MAC Action |
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Provider Action |
On or after 10.1.2022, you may submit any held claims and/or F9/resubmit RTP claims. |
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Proposed Resolution |
The Fiscal Intermediary Standard System (FISS) Maintainer will revise the reason code 32287 edit logic. CR12711 is scheduled to be implemented on 10.3.2022. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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08.11.2022 |
Closed |
All Part A providers |
A system issue caused claims for certain beneficiaries to not process. |
N/A |
N/A |
08.22.2022 |
Updates |
08.22.2022 – This issue is resolved and CGS will release the suspended claims for processing. | |||||
MAC Action |
CGS will suspend affected claims to status/location SMHICN until the issue is resolved. |
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Provider Action |
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Proposed Resolution |
A resolution is in progress. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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03.25.2022 |
Closed |
Multiple |
Cancel claims with a 2022 date of service rejected and posted to the Common Working File (CWF) in error. |
C7113, C7115, C7120, U5600, U5366, etc. |
TOB XX8 |
08.22.2022 |
Updates |
08.22.2022 – This issue is fully resolved. Cancel claims that posted to the CWF between 01.01.2022 and 03.21.2022 in error are no longer present on the CWF. | |||||
MAC Action |
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Provider Action |
08.22.2022 – You may resubmit claims that edited against a cancel claim that posted to CWF in error. |
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Proposed Resolution |
03.21.2022 – A system fix was implemented. Cancel claims submitted after this date will not post to CWF. A resolution for claims that posted to CWF prior to this date is still pending. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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05.02.2022 |
Closed |
Outpatient Hospital (TOB 13X or 85X) |
Outpatient hospital claims with HCPCS codes in designated surgical ranges and modifier PT returned to the provider (RTP'd) with reason code W7120 in error. |
W7120 |
HCPCS codes 10000-69999 or 0000T-9999T with modifier PT |
07.05.2022 |
Updates |
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MAC Action |
CGS will suspend claims to bypass the edit until a system fix is implemented |
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Provider Action |
F9/resubmit claims that returned in error. CGS will then bypass the edit when applicable. |
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Proposed Resolution |
A system fix is tentatively scheduled with the July 2022 quarterly release. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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04.11.2022 |
Closed |
Outpatient Hospital (TOB 13X or 85X) |
Certain outpatient hospital claims for pacemaker battery replacement denied in error. |
5PACE |
HCPCS codes 33206 – 33208 reported with modifier SC and a diagnosis code that is also listed in a modifier KX group |
06.06.2022 |
Updates |
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MAC Action |
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Provider Action |
Reference A54961 – Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers. If you identify a claim that meets the criteria above, request a redetermination (first level of appeal). This will ensure the time limit to request an appeal does not expire while the automated edit is corrected. |
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Proposed Resolution |
CGS will correct the automated edit logic. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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05.24.2022 |
Closed |
SNF and Swing Bed (TOB 21X and 18X (subject to SNF PPS)) |
Patient Driven Payment Model (PDPM) claims with the default HIPPS code that processed on or after April 4, 2022 received an underpayment. |
NA |
HIPPS code ZZZZZ |
05.24.2022 |
Updates |
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MAC Action |
CGS will adjust impacted claims. | |||||
Provider Action |
No provider action is needed. |
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Proposed Resolution |
05.24.2022 – A system fix was installed. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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05.02.2022 |
Closed |
Inpatient Hospital (TOB 11X) |
Inpatient hospital claims with certain diagnosis codes that are exempt from Present on Admission (POA) reporting returned to the provider (RTP'd) with reason code 34931 in error. |
34931 |
Diagnosis codes Z28.310, Z28.311 or Z28.39 |
05.09.2022 |
Updates |
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MAC Action |
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Provider Action |
F9/resubmit claims for processing |
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Proposed Resolution |
05.09.2022 – A system fix was implemented. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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03.08.2022 |
Closed |
FQHC (TOB 77X) |
FQHC claims processed with an incorrect payment due to an error in the Geographic Adjustment Factor (GAF) numbers provided for calendar year 2022. |
NA |
NA |
03.25.2022 |
Updates |
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MAC Action |
04.19.2022 – CGS adjusted FQHC claims with dates of service on or after 01.01.2022 that processed on 01.03.2022 through 03.25.2022. |
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Provider Action |
No provider action is needed |
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Proposed Resolution |
03.25.2022 – The revised CY 2022 FQHC GAF table was implemented. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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02.03.2022 |
Closed |
CAH (TOB 85x) |
Critical Access Hospital (CAH) claims reported with a date of service on or after 01.01.2022, revenue code 037X and an anesthesia HCPCS code are receiving reason code 37575 in error. |
37575 |
Revenue Code 037X; Anesthesia HCPCS code |
03.18.2022 |
Updates |
03.18.2022 – A system fix was implemented. | |||||
MAC Action |
CGS released suspended claims for processing. | |||||
Provider Action |
No provider action is needed. |
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Proposed Resolution |
02.10.2022 – The issue was reported and the Fiscal Intermediary Standard System (FISS) is researching. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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02.03.2022 |
Closed |
Outpatient (TOB 13X and 85X) |
Outpatient hospital claims reported with a date of service prior to 01.01.2022 and an anesthesia HCPCS code are receiving reason code 32402 in error. |
32402 |
Anesthesia HCPCS codes |
03.18.2022 |
Updates |
03.18.2022 – A system fix was implemented. |
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MAC Action |
CGS released suspended claims for processing. |
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Provider Action |
No provider action is needed |
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Proposed Resolution |
02.10.2022 – The issue was reported and a system fix from the System Maintainer is pending. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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02.28.2022 |
Closed |
SNF (TOB 21X and 18X (subject to SNF PPS)) |
The payment rate for Skilled Nursing Facility (SNF) providers that fail Quality Reporting Program (QRP) standards are incorrect. Claims received on or after October 4, 2021, with dates of service on or after October 1, 2021, received a 4% reduction instead of a 2% reduction. |
NA |
NA |
02.22.2022 |
Updates |
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MAC Action |
02.28.2022 – CGS will process claims within 60 days. |
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Provider Action |
NA |
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Proposed Resolution |
02.28.2021 – A corrected version of the Fiscal Year (FY) 2022 SNF Pricer was implemented on 02.22.2022. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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01.31.2022 |
Closed |
Ohio Part A |
Due to a cycle abend, Ohio Part A provider payments may not appear as usual. |
NA |
NA |
02.01.2022 |
Updates |
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MAC Action |
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Provider Action |
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Proposed Resolution |
01.31.2021 – Payments dated 1.31.2022 were not generated but were rolled into the payments dated 2.1.2022. Therefore, Ohio Part A providers may notice EFTs in their accounts on 1.31.2022, none on 2.1.2022, and larger amounts on 2.2.2022. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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10.25.2021 |
Closed |
Hospital (TOB 12X and 13X) |
Coinsurance or deductible should not be applied to COVID-19 vaccine and monoclonal antibodies claims with condition codes MA and 78. |
WW488 |
HCPCS codes 0001A, 0002A, 0011A, 0012A, 0031A, M0239, M0243, M0244, M0245 and M0246 |
10.04.2021 |
Updates |
10.25.2021 – This issue was resolved with the successful implementation of the October 2021 quarterly release. |
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MAC Action |
08.31.2021 – Claims will suspend to status/location SM0488 until the October 2021 quarterly release is installed. |
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Provider Action |
08.31.2021 – No provider action is needed. |
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Proposed Resolution |
08.31.2021 – This issue will be resolved when the October 2021 quarterly release is installed. Claims will then be released to process. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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06.17.2021 |
Closed |
Outpatient Hospital (13X TOB) |
Claims for endoscopy by capsule denied as patient responsibility in error. |
53197, 55504 |
HCPCS codes 91110 and 91111 |
04.16.2021 |
Updates |
06.17.2021 – CGS corrected the system edit and adjusted affected claims. |
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MAC Action |
04.08.2021 – CGS identified an issue with reason code 53197 that caused claims without occurrence code 32 or modifier GA to deny as patient responsibility (reason code 55504) in error. |
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Provider Action |
04.08.2021 – Please reference the CGS Local Coverage Determination (LCD) policy L34081 and Local Coverage Article (LCA) A56461 for additional guidance. |
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Proposed Resolution |
04.08.2021 – CGS will correct the system edit and adjust claims to assign the appropriate reason code (55503). |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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06.17.2021 |
Closed |
SNF |
CMS learned that inpatient SNF claims are being denied when the "From" date of service overlaps the "Through" date of service of a previously processed hospital (TOB 12X) claim for a vaccine (revenue code 0636 or 0771 and a HCPCS code with Type of Service V) or a telehealth service (HCPCS code Q3014) for the same beneficiary. |
38113 |
TOB 21X |
04.05.2021 |
Updates |
06.17.2021 – The system edit logic was corrected with the April 2021 release on April 5, 2021. |
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MAC Action |
11.13.2020 – For claims received on or after April 1, 2021, CGS will override the timely filing edit for services after January 1, 2020 that are no longer timely. See Provider Action steps below. |
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Provider Action |
11.13.2020 – Beginning on April 1, 2021, providers may submit a new claim. Ensure the reason the claim was submitted beyond the timely filing limit is included in the Remarks section. For example: Claim submitted as instructed in CR 11975. |
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Proposed Resolution |
11.13.2020 – FISS will modify the edit logic which will be implemented with the April 2021 release on April 5, 2021. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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06.16.2021 |
Closed |
Outpatient Hospital (TOB 13X) |
CMS identified that a permanent J-code was not established to replace the temporary HCPCS code C9065 (Romidepsin) prior to the July 2021 release. |
NA |
HCPCS Code C9065 |
10.04.2021 |
Updates |
10.25.2021 – This issue was resolved with the successful implementation of the October 2021 quarterly release. |
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MAC Action |
06.16.2021 – CMS instructed MACs to apply a workaround that will allow HCPCS code C9065 to continue to be payable on and after July 1, 2021. |
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Provider Action |
06.16.2021 – No provider action is needed. |
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Proposed Resolution |
06.16.2021 – An Integrated Outpatient Code Editor (IOCE) update is scheduled with the October 2021 release. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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02.15.2021 |
Closed |
Outpatient Hospital (13X TOB) |
Claims for non-invasive vascular studies with dates of service 11.02.2020 – 01.10.2021 may have denied with reason code 53988 in error. |
53988 |
02.15.2021 |
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Updates |
03.29.2021 – Claim adjustments were completed as of 02.15.2021. |
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MAC Action |
01.21.2021 – CGS will identify and adjust claims denied in error. |
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Provider Action |
01.21.2021 – No action required. |
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Proposed Resolution |
01.21.2021 – CGS corrected the system edit on 01.11.2021. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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01.20.2021 |
Closed |
Part A Providers |
We issued some Part A Medical Review post-payment decision letters with an incorrect estimated overpayment amount. The letters were issued for claims denied with reason code 56900 (requested records not received). |
56900 |
NA |
01.20.2021 |
Updates |
01.20.2021 – This issue has been resolved. |
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MAC Action |
01.08.2021 – Once the issue is resolved, CGS will send a letter with the correct estimated overpayment amount for all lines on the claim. |
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Provider Action |
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Proposed Resolution |
01.08.2021 – CGS is researching to resolve the issue. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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01.11.2021 |
Closed |
Part A Hospital OPDs |
Some Part A hospital Outpatient Department (OPD) prior authorization decision letters were issued with digits 4-7 of the MBI populated in the last four digits of the beneficiary's MBI. |
NA |
NA |
01.11.2021 |
Updates |
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MAC Action |
01.11.2021 – CGS identified and corrected the issue. |
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Provider Action |
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Proposed Resolution |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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01.07.2021 |
Closed |
Part A Providers |
CGS identified an error in the system edit logic related to the Local Coverage Determination (LCD) policy L33950, which may have caused some claims for annual screening mammograms to deny with reason code 54300 incorrectly. |
54300 |
HCPCS code 77067; diagnosis code Z12.31 |
01.07.2021 |
Updates |
01.07.2021 –Claim adjustments have been completed. 10.09.2020 – CGS corrected the system edit; claim adjustments are pending. |
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MAC Action |
09.29.2020 – CGS will correct the system edit and adjust any claims denied in error. |
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Provider Action |
09.29.2020 – No provider action is needed. This includes a redetermination request (first level of appeal) as CGS is not able to overturn the claim decision until the system edit is corrected. |
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Proposed Resolution |
09.29.2020 – CGS will correct the system edit and adjust any claims denied in error. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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09.28.2020 |
Closed |
IRF hospitals |
Inpatient Rehabilitation Facility (IRF) claims are being returned (RTP'd) with reason code 37096 (no assessment record on file). |
37096 |
NA |
09.28.2020 |
Updates |
09.28.2020 – iQIES resolved the issue; providers may F9/resubmit claims that RTP'd in error to process. |
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MAC Action |
09.22.2020 – CGS is researching to determine if any claims were RTP'd in error. |
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Provider Action |
09.22.2020 – Prior to calling the Provider Contact Center (PCC), please verify the following:
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Proposed Resolution |
09.28.2020 – iQIES identified and corrected an issue that prevented claims submitted 9.10.2020 – 9.23.2020 to match to the stored IRF-PAI assessment. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
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08.27.2020 |
Closed |
Part A Providers |
We are aware of an issue with inpatient claims receiving reason code 13399 in error. |
13399 |
NA |
10.12.2020 |
Updates |
10.12.2020 – A system correction was successfully implemented with the October release. Providers should F9/resubmit claims for processing. If reason code 13399 still applies, verify the occurrence span codes reported on the claim, make any necessary corrections and F9/resubmit the claim again. |
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MAC Action |
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Provider Action |
08.27.2020 – Additional information will be provided after the successful implementation of the October release. |
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Proposed Resolution |
08.27.2020 – A system correction is scheduled to be implemented with the October release. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
07.29.2020 |
Closed |
Part A Providers |
Reason Code 37578 is causing claims submitted via Direct Data Entry (DDE) to go to the Return to Provider (RTP) file incorrectly. |
37578 |
Physician National Provider Identifier (NPI) |
8.17.2020 |
Updates |
09.25.2020 – This issue has been resolved. A resolution to this issue was implemented on August 17, 2020. 07.09.2020 – Claims are being sent to RTP incorrectly with reason code 37578. CGS is researching the issue. |
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MAC Action |
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Provider Action |
07.09.2020 – No action necessary at this time. |
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Proposed Resolution |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
06.19.2020 |
Closed |
Part A |
Fax not responding |
NA |
NA |
06.19.2020 |
Updates |
08.26.2020 – Resolved and closed. No provider action required. | |||||
MAC Action |
06.19.2020 – CGS has identified the issue and is now resolved | |||||
Provider Action |
06.19.2020 – Providers are to only use the fax number on the OPD PAR form 1.615.782.4486 | |||||
Proposed Resolution |
NA |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
06.05.2020 |
Closed |
Outpatient Hospital (TOB 13X) |
Some claim lines submitted with a medical visit and modifier CS may have processed with coinsurance in error. |
NA |
HCPCS codes assigned status indicator V or J2, or HCPCS code 99291 reported with modifier CS |
08.26.2020 |
Updates |
08.26.2020 – Resolved and closed. No provider action required. | |||||
MAC Action |
06.05.2020 – CGS will identify and correct affected claims. | |||||
Provider Action |
06.05.2020 – No provider action is needed. | |||||
Proposed Resolution |
06.05.2020 – CGS has corrected the error. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
05.14.2020 |
Closed |
Outpatient Hospital (12X TOB) |
CGS became aware of some claims RTP'ing with reason code 32206 incorrectly. |
32206 |
(12X TOB) Revenue Code 078X |
08.26.2020 |
Updates |
08.26.2020 – Resolved and closed. No provider action required. | |||||
MAC Action |
05.14.2020 – CGS identified claims with 12X TOB and Rev code 078X combination RTP'ing in error. | |||||
Provider Action |
05.14.2020 – If claim submitted before 5/14/2020 with 12X TOB and 078X revenue code can be PF9'ed back in for processing. | |||||
Proposed Resolution |
05.14.2020 – CGS has corrected the error. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
04.17.2020 |
Closed |
All Part A providers |
CGS is aware of delays in answering questions that have been submitted to the CGS.ERS.CORR@cgsadmin.com mail box. Our resources have been focused on getting payments made and we are now working through the questions that have been submitted. It may take a few days to work through all the questions but you will get a response as quickly as possible. |
NA |
NA |
06.01.2020 |
Updates |
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MAC Action |
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Provider Action |
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Proposed Resolution |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
04.08.2020 |
Closed |
All Part A providers |
CGS is aware that certain eligible provider types may not have received the maximum eligible amount for their accelerated payment. We are identifying providers impacted by the 3-6 month max issue and determining a resolution. |
NA |
NA |
06.01.2020 |
Updates |
04.15.2020 – Providers who are eligible to receive a 6-month maximum amount and requested an amount greater than their 3-month maximum or requested the "maximum amount" can expect to receive an adjustment to their advance and an additional payment within the next week. |
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MAC Action |
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Provider Action |
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Proposed Resolution |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
01.29.2020 |
Closed |
Outpatient Ambulance Claims |
It has come to the attention of the Centers for Medicare & Medicaid Services (CMS) that the Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) edit 7275 is denying Part B ambulance claims inappropriately. This is occurring when the beneficiary is in a covered Part A SNF stay but requires a Part B covered transport for emergency services and when the transport claim is billed with Healthcare Common Procedure Coding System (HCPCS) code A0427, A0429, or A0433. |
C7275 - Location SM7275 |
HCPCS Codes A0427, A0429, or A0433 |
06.01.2020 |
Updates |
01.01.2020 – A system fix was implemented and this issue is resolved. |
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MAC Action |
10.15.2019 – CGS will manually bypass reason code C7275 for incoming transportation claim lines containing any of the above mentioned HCPCS codes billed with or without A0425. CGS will also hold any associated Informational Unsolicited Responses (IURs) until the C7275 error code and the IUR are revised. The tentative date is January 2020. |
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Provider Action |
NA |
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Proposed Resolution |
10.15.2019 – CGS will reprocess claims brought to their attention that were denied in error. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
02.05.2020 |
Closed |
Outpatient Hospital (13X TOB) |
CGS became aware of some claims RTP'ing with reason code 7TRCR incorrectly. |
7TRCR |
HCPCS Codes A0427, A0429, or A0433 | |
Updates |
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MAC Action |
02.05.2020 – CGS will reprocess affected claims. Planned completion date 02.07.2020. |
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Provider Action |
02.05.2020 – After 02.07.2020 if you feel your claim(s) were not resolved or were missed, you may PF9 the claims back in for processing. |
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Proposed Resolution |
02.05.2020 – CGS has corrected the error. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
01.29.2020 |
Closed |
Outpatient Ambulance Claims |
It has come to the attention of the Centers for Medicare & Medicaid Services (CMS) that the Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) edit 7275 is denying Part B ambulance claims inappropriately. This is occurring when the beneficiary is in a covered Part A SNF stay but requires a Part B covered transport for emergency services and when the transport claim is billed with Healthcare Common Procedure Coding System (HCPCS) code A0427, A0429, or A0433. |
C7275 - Location SM7275 |
Multiple PDPM HIPPS codes | 01.06.2020 |
Updates |
01.01.2020 – A system fix was implemented and this issue is resolved. |
|||||
MAC Action |
10.15.2019 – CGS will manually bypass reason code C7275 for incoming transportation claim lines containing any of the above mentioned HCPCS codes billed with or without A0425. CGS will also hold any associated Informational Unsolicited Responses (IURs) until the C7275 error code and the IUR are revised. The tentative date is January 2020. |
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Provider Action |
NA |
|||||
Proposed Resolution |
10.15.2019 – CGS will reprocess claims brought to their attention that were denied in error. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
01.29.2020 |
Closed |
Skilled Nursing Facility (SNF) and Swing Bed (SB) claims |
The Centers for Medicare & Medicaid Services (CMS) has identified an error in the 2019 Inpatient Facility Prospective Payment System (IPF PPS) currently in production. The Fiscal Year (FY) 2019 IPF PPS Pricer applicable to dates of service on or after October 1, 2018, contains approximately 18 valid Medicare Severity Diagnosis Related Group (MS-DRGs) that are returned to provider (RTP) in error, after receiving an invalid return code '54' from the IPF PPS Pricer. |
WWSNF (Location SMHSNF) |
Multiple PDPM HIPPS codes | 10.07.2019 |
Updates |
11.25.2019 – A system fix was implemented and this issue is resolved. |
|||||
MAC Action |
10.25.2019 – CMS instructed contractors to hold claims that meet the following criteria:
|
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Provider Action |
NA |
|||||
Proposed Resolution |
10.25.2019 – CGS will release all other SNF PDPM claims previously held and reprocess any SNF PDPM claims that were processed in error prior to 10.24.19. |
Date Reported | Status | Provider Type Impacted | Description of Issue | Reason Codes | Claim Coding Impact | Date Resolved |
---|---|---|---|---|---|---|
01.29.2020 |
Closed |
All Types of Bill |
The Centers for Medicare & Medicaid Services (CMS) is aware of an issue causing the Medicare Beneficiary Identifier (MBI) on the incoming claim to link to an inactive Health Insurance Claim Number (HICN). This is impacting a limited number of claims. |
38119, 30918, 30905, F5050, U5050, U5062 |
MBI | 12.18.2019 |
Updates |
01.01.2020 – A system fix was implemented and this issue is resolved. 10.17.2019 – The correction date for this issue has been delayed until November 18, 2019. 09.19.2019 – The claims affected by this issue are being suspended in status/location S MHMBI. A resolution to this issue has been scheduled for implementation on October 7, 2019. At that time, the claims will be released to continue processing. |
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MAC Action |
||||||
Provider Action |
09.19.2019 – No action required. |
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Proposed Resolution |
09.19.2019 – A resolution to this issue has been scheduled for implementation on October 7, 2019. |