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J15 Part A Resolved Claims Issues

Updated: 02.16.24

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

 

MAC Action

 

Provider Action

You may F9/resubmit any claims that received reason code 32226 in error.

Proposed Resolution

11.27.2023 – A system correction was installed.

A system correction is tentatively scheduled. We will provide updates when available.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

 

MAC Action

 

Provider Action

You may F9/resubmit claims that RTP'd in error.

Proposed Resolution

A system update was implemented with the July 2023 quarterly release.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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;
Dates of service 05.01.22 – 06.13.23;
Line item DOS for dialysis is within 120 days of the initial date of first dialysis

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.

MAC Action

CGS will adjust affected ESRD claims within 120 days of a provider’s request. See Provider Action below.

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.

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.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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
Modifier CG
Claims processed 5.15.2023 – 6.12.2023

07.31.2023

Updates

 

MAC Action

Claim adjustments occurred on 7.31.2023.

Provider Action

N/A

Proposed Resolution

The system logic was corrected on 6.12.2023.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

 

MAC Action

Per CMS instructions, CGS will adjust/reprocess claims that paid on 09.28.2022 through 09.30.2022.

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.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

 

MAC Action

 

Provider Action

On or after 10.1.2022, you may submit any held claims and/or F9/resubmit RTP claims.

Proposed Resolution

The Fiscal Intermediary Standard System (FISS) Maintainer will revise the reason code 32287 edit logic. CR12711External PDF is scheduled to be implemented on 10.3.2022.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

Provider Action

 

Proposed Resolution

A resolution is in progress.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

 

Provider Action

08.22.2022 – You may resubmit claims that edited against a cancel claim that posted to CWF in error.

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.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

MAC Action

CGS will suspend claims to bypass the edit until a system fix is implemented

Provider Action

F9/resubmit claims that returned in error. CGS will then bypass the edit when applicable.

Proposed Resolution

A system fix is tentatively scheduled with the July 2022 quarterly release.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

MAC Action

 

Provider Action

Reference A54961 – Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac PacemakersExternal Website.

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.

Proposed Resolution

CGS will correct the automated edit logic.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

MAC Action

CGS will adjust impacted claims.

Provider Action

No provider action is needed.

Proposed Resolution

05.24.2022 – A system fix was installed.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

MAC Action

 

Provider Action

F9/resubmit claims for processing

Proposed Resolution

05.09.2022 – A system fix was implemented.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

 

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.

Provider Action

No provider action is needed

Proposed Resolution

03.25.2022 – The revised CY 2022 FQHC GAF table was implemented.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

Proposed Resolution

02.10.2022 – The issue was reported and the Fiscal Intermediary Standard System (FISS) is researching.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

MAC Action

CGS released suspended claims for processing.

Provider Action

No provider action is needed

Proposed Resolution

02.10.2022 – The issue was reported and a system fix from the System Maintainer is pending.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

MAC Action

02.28.2022 – CGS will process claims within 60 days.

Provider Action

NA

Proposed Resolution

02.28.2021 – A corrected version of the Fiscal Year (FY) 2022 SNF Pricer was implemented on 02.22.2022.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

MAC Action

Provider Action

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.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

MAC Action

08.31.2021 – Claims will suspend to status/location SM0488 until the October 2021 quarterly release is installed.

Provider Action

08.31.2021 – No provider action is needed.

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.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

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.

Provider Action

04.08.2021 – Please reference the CGS Local Coverage Determination (LCD) policy L34081 and Local Coverage Article (LCA) A56461 for additional guidance.

Proposed Resolution

04.08.2021 – CGS will correct the system edit and adjust claims to assign the appropriate reason code (55503).

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

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.

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.

Proposed Resolution

11.13.2020 – FISS will modify the edit logic which will be implemented with the April 2021 release on April 5, 2021.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

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.

Provider Action

06.16.2021 – No provider action is needed.

Proposed Resolution

06.16.2021 – An Integrated Outpatient Code Editor (IOCE) update is scheduled with the October 2021 release.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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

A56697 – Billing and Coding: Non-Invasive Vascular StudiesExternal Website

02.15.2021

Updates

03.29.2021 – Claim adjustments were completed as of 02.15.2021.

MAC Action

01.21.2021 – CGS will identify and adjust claims denied in error.

Provider Action

01.21.2021 – No action required.

Proposed Resolution

01.21.2021 – CGS corrected the system edit on 01.11.2021.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

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.

Provider Action
Proposed Resolution

01.08.2021 – CGS is researching to resolve the issue.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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
MAC Action

01.11.2021 – CGS identified and corrected the issue.

Provider Action
Proposed Resolution

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

MAC Action

09.29.2020 – CGS will correct the system edit and adjust any claims denied in error.

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.

Proposed Resolution

09.29.2020 – CGS will correct the system edit and adjust any claims denied in error.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

MAC Action

09.22.2020 – CGS is researching to determine if any claims were RTP'd in error.

Provider Action

09.22.2020 – Prior to calling the Provider Contact Center (PCC), please verify the following:

  • The patient assessment was on file in QIES prior to submitting the claim.
  • The information submitted on the claim is an exact match to the information submitted in QIES.
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.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

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.

MAC Action  
Provider Action

08.27.2020 – Additional information will be provided after the successful implementation of the October release.

Proposed Resolution

08.27.2020 – A system correction is scheduled to be implemented with the October release.

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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.

MAC Action  
Provider Action

07.09.2020 – No action necessary at this time.

Proposed Resolution  

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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

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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.

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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.

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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  
MAC Action  
Provider Action  
Proposed Resolution  

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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.

MAC Action  
Provider Action  
Proposed Resolution  

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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.

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.

Provider Action

NA

Proposed Resolution

10.15.2019 – CGS will reprocess claims brought to their attention that were denied in error.

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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  
MAC Action

02.05.2020 – CGS will reprocess affected claims. Planned completion date 02.07.2020.

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.

Proposed Resolution

02.05.2020 – CGS has corrected the error.

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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.

Provider Action

NA

Proposed Resolution

10.15.2019 – CGS will reprocess claims brought to their attention that were denied in error.

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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:

  • Type of Bill (TOB) 21X and 18X subject to SNF PDPM
  • From date 10.1.19 and after
  • Multiple line items with revenue code 0022
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.

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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.

MAC Action  
Provider Action

09.19.2019 – No action required.

Proposed Resolution

09.19.2019 – A resolution to this issue has been scheduled for implementation on October 7, 2019.

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