LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


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October 30, 2014 - Revised: 02.07.23

Reimbursement for Drugs & Biologicals: How Are Payments Calculated?

CGS reimburses drugs and biologicals using one of several methodologies:

  • Center for Medicare & Medicaid Services (CMS) Average Sales Price (ASP)
  • CMS Not Otherwise Classified (NOC) Pricing File
  • Wholesale Acquisition Cost (WAC) or invoice pricing
  • Other pricing methodology (employed for some radiopharmaceuticals)

For drugs and biologicals reimbursed using CMS's ASP methodology:

  • No invoice is needed for drugs reimbursed using this methodology.
  • Payment is based on 106 percent of the ASP.
  • There are several exceptions to the ASP payment methodology, including: blood and blood products; drugs infused through a covered item of Durable Medical Equipment; and certain vaccines.
  • ASP and NOC pricing files are available on the CMS websiteExternal Website.

For drugs or biologicals reimbursed using WAC or invoice pricing:

  • WAC pricing applies to drugs that are not reimbursed based on CMS's ASP or NOC Pricing Files.
    • No invoice is needed when a WAC amount is available. ¬†When WAC pricing is available, CGS calculates reimbursement based on the WAC amount from the Redbook.
    • The payment limit is based on the lesser of the lowest brand or median generic WAC.
    • The payment allowance for new drugs that were first sold on or after January 1, 2005, is based on 106 percent of the WAC.
    • Information on determining WAC pricing is available in CMS Medicare Claims Processing Manual, chapter 17, section 20.1.3 on the CMS websiteExternal Website.
  • When invoice pricing is used, each Medicare contractor determines how many invoices are necessary to determine the reimbursement amount.
    • CGS requires that invoices be submitted with each claim when the drug or biological is not priced based on ASP and there is no WAC available.

For radiopharmaceuticals (HCPCS codes A9500-A9700):

  • CMS has established pricing information for some radiopharmaceuticals. Those radiopharmaceuticals with established reimbursement amounts do not require additional invoice information, as described below. Drugs with an established reimbursement are listed on the CMS websiteExternal Website.
  • For radiopharmaceuticals other than those listed on the CMS website (with established reimbursement):
    • Claims for radiopharmaceuticals must be submitted with either a copy of the actual invoice or invoice information must be included on the electronic claim itself.
  • The name of the drug, radiopharmaceutical, or skin substitute and the exact dosage administered/used must appear in the Documentation Field.
    • For electronic claims, report invoice information in the Electronic Documentation Field Loop 2300, NTE Segment (header level) or Loop 2400, NTE Segment (line level).
    • If you are approved to submit paper claims, report this information in Item 19 of the CMS-1500 claim form and provide a copy of the actual invoice.
  • If the charge matches the actual invoice cost, note "Actual Invoice Cost" in the Documentation Field. You are not required to submit invoice information with the claim; however, it must be available if requested.
  • If you are submitting a charge greater than the actual invoice cost, please include the following information in the Documentation Field, using these abbreviations:
    • Des = Description/Name of agent (e.g., Des=TC99m MDP)
    • QS = Quantity shipped (e.g., QS=100 mci)
    • TA = Total amount charged for quantity shipped in dollars and cents with the decimal (e.g., TA=$57.40)
    • UP = Unit Price in dollars and cents with the decimal (e.g., UP = $0.57 per mci) (Optional)
    • DG = Dosage administered/amount used (e.g., DG=25 mci)
  • In lieu of submitting the invoice information, you may use the Paperwork (PWK) process and send a copy of the invoice via fax or mail Details on the PWK Segment Process.
  • Claims requiring invoice submitted without the above information or the actual invoice may be denied or delayed.

References:

Revised: 02.07.23

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