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EDI Status

CPILClaims Processing Issues Log

Listed below are current system-related claims processing issues. Issues are shown by date reported with the most recently reported issue listed first. This log is updated frequently, as soon as information becomes available. CGS encourages you to review this log often and prior to contacting the Provider Contact Center. A list of resolved issues is also available at the end of this list. If you still have questions, please contact the Provider Contact Center or use one of our self-service tools.

Date Reported Description of Issue
07.29.2020 – Closed The existing requirements related to Skilled Nursing Facility (SNF) consolidated billing (CB) remain in place during the public health emergency (PHE). The telephone evaluation and management (E/M) services are not excluded from SNF CB because the service when rendered via telehealth would not be coverable at all under normal circumstances. Due to the waivers during the PHE, these services are payable and should be excluded from SNF CB. Services submitted have been denied or recouped.
07.14.2020 COVID lab tests were denying against our routine DX edit in error. This was corrected and denials for this would no longer happen as of 07/15/2020 as tech got an email about the same issue and corrected last week.
07.17.2020 – Closed CPT code 0518F and other codes were included in a range of codes that hit an edit in error. Additional documentation request (ADR) letters were sent to providers in error requesting documentation. The edit should only send ADRs on category III codes and end in 'T' when no documentation is sent with the claim.
04.17.2020 – Closed HCPCS code J3301 was added to the Self-Administered Drug list in error. This caused claims to deny stating "No coverage when self-administered."
04.16.2020 We are researching telehealth (audio and visual) claims denying for modifier 95. No provider action needed at this time.

**NOTE: Providers who conduct audio-only communication (no video or visual) may bill CPT codes 98966-98968 and CPT codes 99441-99443. It is not necessary to append the 95 modifier to these telephone codes, as these are not face-to-face services.
02.04.2020 Denial of debridement of mycotic nails that do not require a class findings modifier.
10.15.2019 – Closed 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.
01.24.2019 A system edit allowed the payment of vaccine administration codes when the vaccine was not submitted on the claim. This has resulted in overpayments.

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