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.

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  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.
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  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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Appeals Data Analysis

Part B Redeterminations

Claim denials are subject to Redetermination since a denial is considered a payment determination. A Redetermination is the first level of appeal after the initial determination on a claim. CGS staff involved with the initial claim determination does not complete the Redetermination.

There are some denials that can be avoided, thus reducing the need to request a Redetermination. Upon analysis of receipts, we found a number of common issues that, if billed appropriately, would save a lot of TIME and MONEY for you (by way of correctly processed claims upon initial submission), and would eliminate a substantial number of requests for us.

Please share this information with your coding and billing staff.

ISSUE

SOLUTION

Duplicate Services

When submitting the same service rendered on the same patient on the same date by the same provider, submit them on the same claim and use the UNITS field (electronic equivalent of Item 24G PDF of the CMS-1500 claim form) to identify multiple services were provided.

  • If services are submitted on separate claims or on separate detail lines of the same claim, they may deny as duplicate.
  • Be sure to submit bilateral services using one of the appropriate modifiers to avoid incorrect duplicate denials.

In cases where you absolutely cannot combine like services and submit them on the same claim, please use CPT modifier 76 or 91 on the subsequent service(s). Refer to the Modifier Finder Tool for details on these modifiers.

When billing multiple units, consider the Medically Unlikely Edits (MUEs).

  • MUEs were created to reduce inappropriate payments that result from billing the incorrect number of units.
  • CMS published a MUE table External Websitethat includes the maximum units that may be billed on SOME codes. If you do not find the code in question on the table, it is confidential so it cannot be published. Check with your State and/or national specialty medical societies or associations for assistance.
    • Under the "Related Links" section, select the Practitioner Services MUE Table effective for the date of service in question, as the MUE values may be updated on a quarterly basis.

To prevent a duplicate denial when performing a medically necessary service that exceeds the MUE value:

  • Bill one line up to the MUE value;
  • Bill a second line (on the same claim) for the additional units and add CPT modifier 76.

If you received payment on a claim that needs to have additional units added, please request a Reopening of the claim to increase the number of units and billed amount of the claim (as long as the number of units does not exceed the Medically Unlikely Edit (MUE) value).

We are receiving Redetermination requests for incorrect duplicate denials with modifiers that are used to bypass the Correct Coding Initiative (CCI) edits. Using a CCI modifier to let us know the same service was performed multiple times on the same day will not pass our duplicate audit.

  • Please refer to the Modifier Finder Tool and review the information for CPT modifier 59, XE, XS, XU, and XP to learn more about CCI.

Concurrent Care Denials

In most cases, Medicare will pay for one service. A second service or procedure MAY be considered for payment only in unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the service feels another physician's expertise is needed.

  • In this situation, the second service performed on the same date of service should be submitted with CPT modifier 77.
    • Refer to the Modifier Finder Tool for details. Please be sure the patient's record support using this modifier.
  • If you've had a service deny for this reason, please resubmit the service with CPT modifier 77 (provided you have documentation to support using the modifier.)
  • You may also request a Reopening to add CPT modifier 77 to the service.
  • If the service still denies for Concurrent Care, please request a Redetermination and include documentation from each provider who performed the service.

This does not apply to Evaluation & Management (E/M) services. Please check here for information on concurrent E/M services.

Medicare does not pay for another interpretation for EKGs to be provided in the Emergency Room unless there is a questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed, or the diagnosis was changed as a result of the second interpretation.

  • When multiple x-rays and EKGs are performed in the Emergency Room setting, those services should be submitted with CPT modifier 76 (same physician) or 77 (different physician) as appropriate.
    • Please be sure the patient's record is documented appropriately.
  • A Redetermination is required for services denied for this reason.
    • When appealing this service, it is best to include the interpretation reports from each provider and/or an explanation of why the service had to be performed more than once.
  • Refer to the CMS Internet-Only Manual, Pub. 100-04, Chapter 13, Section 100.1External PDF for additional information.

This does not apply to Evaluation & Management (E/M) services. Please check here for information on concurrent E/M services.

Evaluation & Management (E/M services) - Denials may be prevented by including the following information with the initial claim submission:

  • Electronic claims: include the billing provider's sub-specialty designation (both the numeric AND narrative sub-specialty description are required) in either NTE 2300 Loop or Line NTE in the 2400 Loop
  • Paper claims: include the billing provider's sub-specialty designation in Item 19
  • The claim line diagnoses listed should be specific to the reason for the billed visits

Please check here for information on concurrent E/M services.

Redeterminations and Overpayments

Please be sure all departments within your organization are in agreement with how to handle claims and appeal requests.

SCENARIO: We process and pay a service. The provider's Finance department feels the service was paid in error so an unsolicited refund request is submitted to CGS. The billing department receives the remittance where the refund was applied and they request a redetermination stating the service was necessary.

Coordination among all departments is very important. In this scenario, please submit a new claim instead of requesting a Redetermination.

Denials Based on a Local Coverage Determinations (LCDs)

Reference our Local Coverage Determinations (LCDs) to check coverage and frequency limitations, if applicable. Our LCDs indicate our definition of medical necessity, identifying allowed CPT/HCPCS and ICD-10 codes.

For faster processing, claims that have been denied may be filed as new claims if you have a corrected diagnosis code. Please request an appeal if the medical record does not support a different (allowed) diagnosis code, but you have other documentation to support payment of the service.

Tips and Reminders

  • Please do not submit a Redetermination request to "correct a claim." The Reopenings process is more appropriate to correct minor errors or omission on previously processed claims.
  • Redetermination requests must contain medical documentation for each service being appealed. Multiple radiology or lab services require documentation that supports each occurrence and/or records from each provider billing for that particular service.

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