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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.

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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.

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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.

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April 30, 2020 - Updated 01.24.24

277CA Report CGS ACE Smart Edits Listing

CGS is excited to announce we have successfully implemented several enhancements to the 277CA report, as part of our CGS Advance Communication Engine (ACE) Smart Edits. CGS ACE Smart Edits is a process that returns pre-adjudicated claims information through claim acknowledgement transaction reports based on the Medicare 277CA. This system populates the STC*12 segment in the 2220D loop of the 277CA.

Most claims hitting the CGS ACE pre-adjudication editing process are not forwarded to the claims adjudication system. After reviewing these claims, you will decide if you should update or not update the claim and then, just resubmit it for processing. Some claims may hit a CGS ACE Informational Smart Edit that returns important messaging for your practice while allowing the claim to forward to the claims processing system. We encourage you to review your 277CA report for these messages. A list of the active CGS ACE Smart Edits is found below.

All direct submitters will receive the Medicare 277CA report with these new Smart edits. If you are currently using a clearinghouse or billing service to submit your claims, please share this information with them and make sure they are providing you a detailed 277CA report. Examples of how the segment will appear can be found in our current GPNet Communications ManualPDF.

CGS Advance Communication Engine (ACE) Smart Edits List As Returned on the 277CA

Claims hitting these CGS ACE pre-adjudication Smart Edits are not forwarded to the claims adjudication system. Please review the claim and if you choose not to change the claim, then just resubmit it for processing.

Smart Edits # Smart Edits Message Smart Edits Description
001PPRM The current claim line contains HCPCS J code XXXXX and the submitted charge is greater than or equal to $10,000.00. The claim line should be reviewed for potential overpayment. (001PPRM) J Code with Billed Amount Greater Than 10,000
The 001PPRM System Rule identifies claim lines submitted with a procedure code beginning with 'J' and the billed amount is greater than or equal to $10,000.00.
032POVP This claim line has a radiology CPT code in the same body area as a radiology procedure code on this claim. Please review for appropriate payment. (032POVP) Multiple Radiology Different Claim
The 032POVP System Rule identifies claim lines with multiple radiology procedures for the same body area.
ADR CGS is pending response from your agency for an ADR for one or more claims. Please refer to your ADR letter(s) for more details. Please see link. https://www.cgsmedicare.com/mycgs/index.html (ADR) Additional Documentation Request
An informational message received when a submitter is non-responsive to a Post payment Medical Review ADR Letter. MR ADR Response Forms are available as a self-service tool function via myCGS.
BAG Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Age relationship criteria for CMS ID(s) XXXX. (BAG) LCD Part B Procedure Not Typical with Patient Age
The BAG edit identifies claims containing CPT codes that can only be performed with a specified age per LCD/NCD
BCC Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Code-to-Code relationship criteria for CMS ID(s) XXXXX. (BCC) LCD Part B Code to Code Missing or Invalid
The BCC edit identifies claim lines that do not meet an LCD policies requirement for a code to code relationship.
BPO Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Place of Service relationship criteria for CMS ID(s) XXXXX. (BPO) LCD Part B Invalid Place of Service
The BPO edit identifies claims containing CPT codes that can only be performed in specified Place(s) of Service per LCD/NCD policy.
CAG Procedure Code XXXXX is not typical for a patient whose age is XX. The typical age range for this procedure is YY - XX. (CAG) Procedure Not Typical with Patient Age
The CAG System Rule identifies claim lines that contain a patient's age not typical for the procedure code.
NEW
cGE
(cGE) Per Medicare guidelines this procedure code XXXXX is not covered when billed with modifier on date of service. (cGE) Procedure code was submitted with an invalid modifier for this date of service. Please review modifier.
cIPPE Initial Preventative Physical Examination services are allowed during the first 12 months of a beneficiary’s enrollment in Medicare. Please review. (cIPPE) Initial Preventive Physical Examination Billed Outside of Coverage Period
The cIPPE edit identifies services that are billed after the 12 month coverage period has passed.
CSX Procedure code XXXXX is not typically performed for a patient whose gender is X. (CSX) Procedure Not Typical with Patient Gender
The CSX System Rule identifies claim lines that contain a patient's gender not typical for the procedure code.
DLP This line is a possible duplicate of another line billed by the same provider for the same date of service on this claim. (DLP) ACE Duplicate Line by Provider
The DLP System Rule identifies claim lines that are possible duplicate of another claim line on the same claim.
DME Per the DMEPOS Jurisdiction List, code XXXXX should be submitted to the DME Medicare Administrative Contractor (MAC). (DME) Durable Medical Equipment
The DME edit will set when a DME code is submitted to Part B.
DTU Discrepancy detected between the number of units XXXXX on this claim line and the difference between the Beginning date of service mm/dd/yyyy and the Ending date of service mm/dd/yyyy which is XX days. (DTU) Date of Service to Units Discrepancy
The DTU System Rule identifies claim lines where the number of units entered is not equal to the date span starting from Beginning date of service to the Ending date of service.
IMC Modifier XX cannot be billed on the same claim line as modifier YY. (IMC) Inappropriate Modifier Combination
The IMC edit identifies claim lines that contain modifiers that cannot be on the same claim line together.
INFO A potential coding error was identified with this claim; please see STC 2220D Loop for specific information. If you wish to continue without updates, please resubmit the claim in its current state to bypass additional Smart Editing. (INFO) Informational Edit
An informational message the submitter will receive when a review flag sets on a claim.
ISX Diagnosis code(s) XXXXX typically would not be reported for a patient whose gender is X. (ISX) Diagnosis Not Typical with Patient Gender
The ISX System Rule identifies claim lines that contain a diagnosis code not typical for a patient's gender.
LBI Per LCD or NCD guidelines, procedure code XXXXX has not met the associated diagnosis code relationship criteria for CMS ID(s) XXXXX. (LBI) LCD Part B Missing or Invalid Diagnosis
The LBI is issued if a diagnosis code does not meet guidelines for a policy with non-sequenced diagnosis codes.
LBM Per LCD or NCD guidelines, procedure code XXXXX has not met the associated Modifier Code relationship criteria for CMS ID(s) XXXXX. (LBM) LCD Part B Missing Required Modifier
This edit identifies claims containing CPT codes that require a modifier per LCD/NCD guidelines.
mAM Per Medicare guidelines, HCPCS code XXXXX is identified as an ambulance code and requires an ambulance modifier appended. mAM Medicare Ambulance Modifiers
Per Medicare, ambulance HCPCS codes require an ambulance modifier. This edit will fire if an ambulance modifier is not included.
mANM Anesthesia code on this line requires an appropriate modifier. (mANM) Medicare Anesthesia Modifiers
The mANM edit will analyze all claim lines to determine if an anesthesia code has been billed without an appropriate anesthesia modifier appended to the line.
mAS Medicare statutory payment restriction for assistants at surgery applies to the procedure XXXXX. (mAS) Medicare No Payment for Assistant Surgeons
The mAS edit identifies claim lines that contain an assistant surgeon modifier and a procedure code that Medicare typically does not allow reimbursement for surgical assistants.
mAT Per Medicare guidelines procedure code XXXXX requires HCPCS modifier GP, GO, or GN. (mAT) Medicare Always Therapy
The mAT edit fires when a therapy procedure codeExternal website is submitted and required HCPCS modifier GP, GO or GN is not on the detail line.
mAWS Annual Wellness Visit services billed out of sequence. (mAWS) Subsequent Medicare Annual Wellness Visit Billed Before Initial Annual Wellness Visit.
The mAWS edit identifies the annual wellness visit services billed out of sequence. The subsequent code (G0439) billed before the initial code (G0438).
MBI Medicare will only accept MBIs after December 31, 2019. Use our myCGS portal if your patients do not have their Medicare cards at the time of service. Please refer to the MBI Look-Up Tool job aid for help. If not registered to use myCGS, please refer to the myCGS webpage. (MBI) Medicare Beneficiary Identifier
The MBI rule identifies claims that are not submitted with a MBI.
mCO Billing for co-surgeons is not permitted for the procedure XXXXX. (mCO) Medicare Co-Surgeons Not Permitted
The mCO edit identifies claim lines that contain a co-surgeon modifier and a procedure code that Medicare typically does not allow reimbursement for co-surgeons.
mC35 Per Medicare guidelines this procedure code XXXXX is not covered by this specialty. Please review procedure and specialty. (mC35) Procedure code will set when billed by this specialty.
mDP Procedure Code XXXXX is within the global period of XX days of History Procedure Code YYYYY performed on mm/dd/yyyy by the same provider. The diagnosis indicates it is not for the same condition. Please review to determine if a modifier is appropriate. (mDP) Medicare Post-Op Unrelated Service by Provider
If a Medicare E/M procedure code was submitted within the Follow-up days determined for services by the same provider, same department and specialty for a different diagnosis code then the mDP edit is fired.
mDT Per the Medicare Physician Fee Schedule, Procedure Code XXXXX describes a diagnostic procedure that requires a professional component modifier in this POS XX. (mDT) Medicare Diagnostic Testing in a Hospital Setting
The mDT edit identifies claim lines which have procedure codes that are diagnostic tests performed in an Inpatient or Outpatient hospital or skilled nursing setting. When a provider is billing these services in an Inpatient or Outpatient hospital or skilled nursing setting, only the professional component should be billed (modifier 26).
mEM
  • E/M code XXXXX should not be billed on the same date of service as a minor procedure without an appropriate modifier.
  • E/M code XXXXX should not be billed without an appropriate modifier on the same date of service or one day prior as a major procedure.
(mEM) Medicare E/M and Surgery without Modifier
The mEM edit identifies claim lines where an E/M code is billed without CPT modifier 25 on the same date of service as a minor surgical procedure; or billed without CPT modifier 57 on the same date of service or one day before a major surgical procedure.
mFP Procedure Code XXXXX is within the global period of XX days of History Procedure Code YYYYY performed on mm/dd/yyyy by the same provider. The diagnosis indicates it is for the same condition. Please review to determine if a modifier is appropriate. (mFP) Medicare Global Follow-Up by Provider
The Medicare E/M Global Follow-Up System rule determines whether an E/M service was billed within the follow-up period of a prior service. If a Medicare E/M procedure code was submitted within the Follow-up days determined for services by the same provider, department and specialty with the same diagnosis code then mFP edit is fired.
mGT Per the Medicare Physician Fee Schedule, procedure code XXXXX describes the global code of a service or diagnostic test. Use of modifier XX is inappropriate for the procedure code. (mGT) Medicare Global Test Only
The mGT Medicare Rule identifies claim lines which have stand-alone global diagnostic test codes and the modifier 26 or TC are attached, this is indicated by the PC/TC Indicator of 4. Modifiers 26 and TC are inappropriate with these codes.
mIM
  • Modifier 26 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule.
  • Modifier TC is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule.
  • A Co Surgeon Modifier 62 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule.
  • A Team Surgeon Modifier 66 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule.
  • An assistant surgeon modifier XX is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule.
  • A Multiple Procedure Modifier 51 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule.
  • Modifier 22 is not appropriate for Procedure Code XXXXX, as per Medicare Fee Schedule
(mIM) Medicare Inappropriate Modifier
The mIM edit identifies claim lines that contain a modifier that is not appropriate for the given procedure code per the Medicare Physician Fee Schedule (MPFS).
mIN Per Medicare guidelines, procedure code XXXXX is considered a bundled service when procedure code YYYYY is billed on the same day by the same provider. (mIN) Medicare Injection Service
The mIN edit identifies claim lines that contain an injection service, status indicator of “T” in the Medicare Physician Fee Schedule (MPFS), and a procedure with a status indicator of “A”, meaning active; the injection services are deemed not payable by Medicare.
mIPW Per Medicare, within the first 12 months of Part B coverage, the initial preventive physical examination for procedure code XXXXX must be billed prior to the annual wellness visit code XXXXX. Please Review. (mIPW) Initial Preventive Physical Examination billed prior to the annual procedure code.
The Initial Preventive Physical Examination is allowed during the first 12 months of Part B coverage instead on the Annual Wellness Visits.
mMOD Per Medicare, use of modifier XX is not typical for procedure code XXXXX. (mMOD) Medicare Modifier Code Not Typical for Procedure Code
The mMOD edit identifies a procedure codes(s) that are submitted with a modifier(s) that is not typical for the procedure code.
mNP Procedure Code XXXXX does not typically require performance by a physician in Place of Service XX, per Medicare Guidelines. (mNP) Medicare Non-Physician Service
The mNP edit identifies claim lines that contain a certain place of service (hospital Inpatient, hospital Outpatient, or nursing facility residents) and a PC/TC status indicator of 5. These procedures typically do not require performance by a physician.
mPC Per the Medicare Physician Fee Schedule, Procedure XXXXX describes the physician work portion of a diagnostic test. Modifier XX is not appropriate. (mPC) Professional Component Only
The mPC flag identifies the claim lines which have procedure codes, per the MPFS, a PC/TC indicator of 2, that represent the professional portion of selected diagnostic tests and the 26 or TC modifier is attached. The modifiers 26 or TC are not appropriate. The PC/TC concept does not apply since these services cannot be split into professional and technical components.
mPI Per the Medicare Physician Fee Schedule, Procedure Code XXXXX describes a physician interpretation for this service and is inappropriate in POS XX. (mPI) Medicare Physician Interpretation
The mPI Medicare Rule Identifies claim lines Ih have the Inpatient professional component of clinical laboratory codes, this is indicated by the PC/TC indicator of 8 in the MPFS, and a non-inpatient place of service is present. Billing of the technical component is inappropriate.
mPS Per the Medicare Physician Fee Schedule, the PC/TC concept does not apply to Procedure XXXXX. Use of modifier XX is inappropriate. (mPS) Medicare Physician Service Code
The mPS flag identifies the claim lines which have codes that describe physician services, PC/TC indicator is '0' and a 26 or TC modifier is present. The concept of professional and technical components splits (PC/TC) does not apply since physician services cannot be split into professional and technical components. Modifiers -26 (Professional), and -TC (Technical) cannot be used with these codes.
mSP Per Medicare guidelines procedure code XXXXX is within the global period of history procedure code YYYYY performed on mm/dd/yyyy by the same provider. Review documentation to determine if a modifier is appropriate. (mSP) Medicare Post-Op Surgery By Provider
The mSP edit identifies claim lines that contain a date of service and a surgical procedure code that is submitted within the follow-up (global) days of surgical procedure, by the same physician.
mSP Per Medicare guidelines procedure code XXXXX performed on mm/dd/yyyy by the same provider is within the global period of XXXXX. (mSP) Medicare Post-Op Surgery By Provider
The mSP edit identifies claim lines that contain a date of service and a surgical procedure code that is submitted within the follow-up (global) days of surgical procedure, by the same physician.
mTC Per the Medicare Physician Fee Schedule, Procedure XXXXX describes only the technical portion of a service or diagnostic test. Modifier XX is not appropriate. (mTC) Medicare Technical Component Only
The mTC Medicare Rule identifies the claim lines which have procedure codes that represent the technical portion of selected diagnostic tests and a 26 or TC modifier is present. The PC/TC concept does not apply since these services cannot be split into professional and technical components.
mTF The date of service is past Medicare timely filing guidelines. (mTF) Medicare Timely Filing
The mTF timely filing rule will fire on claims when submitted past the timely filing requirements established by The Centers for Medicare and Medicaid Services (CMS).
mTS Team Surgery is not permitted for Procedure XXXXX. (mTS) Medicare Team Surgeons Not Permitted
The mTS edit identifies claim lines that contain a team surgeon modifier and a procedure code that Medicare typically does not allow reimbursement for team surgeons.
mUN Per the Correct Coding Initiative (CCI), procedure code XXXXX has an unbundle relationship with procedure code XXXXX billed on the same date of service. (mUN) Unbundled Procedure on Separate Claim – (History Edit)
The mUN Medicare Unbundle System Rule verifies if the procedure code on the current line and any other procedure codes billed for the same patient on the same day by the same provider can be billed together, as per Medicare. If there is another procedure in the patient's history which should not be billed with the current line's procedure code, the respective Unbundle flag is fired.
mUO Per the Correct Coding Initiative (CCI), procedure code XXXXX has an unbundle relationship with procedure code XXXXX billed on the same date of service. Review documentation to determine if a modifier override is appropriate. (mUO) Unbundled Procedure on Current Line, Possible Modifier Override
The mUO Medicare Unbundle System Rule verifies if the procedure code on the current line and any other procedure codes billed for the same patient on the same day by the same provider can be billed together, as per Medicare. If there is another procedure in the patient's history which should not be billed with the current line's procedure code, the respective Unbundle flag is fired.
NPT The patient received care by this provider within the last three years. An established patient E/M code should be used. (NPT) New Patient Code Billed for Established Patient Claim History
The NPT flag identifies when the patient history indicates the patient has been seen by the same provider within 3 years of the current claim line's beginning date of service.
PCM Modifier -26 is not appropriate with Procedure Code XXXXX because that procedure is defined as 100% professional or 100% technical. (PCM) Invalid Professional Component Modifier
The PCM edit identifies claim lines that contain a procedure code that is considered 100% technical and modifier 26 is appended.
 
POS
Procedure Code XXXXX is not typically performed by a provider in Place of Service XX. (POS) Place of Service Not Typical with Procedure
The POS System Rule identifies claim lines that contain a place of service that the specified procedure is not typically performed in.
PVN1 Your Medicare enrollment record is due for revalidation. Failure to respond may result in a hold on payments and possible deactivation of your enrollment. (PVN1) Enrollment Record Revalidation
An informational message the submitter will receive when your Medicare enrollment record is due to revalidation.
PVN2 Your Medicare enrollment record is due for revalidation. Failure to respond may result in a hold on payments and possible deactivation of your enrollment. (PVN2) Enrollment Record Revalidation
An informational message the submitter will receive when your Medicare enrollment record is due to revalidation.
PVNE Your Medicare enrollment record is due for revalidation. Failure to respond may result in a hold on payments and possible deactivation of your enrollment. (PVNE) Enrollment Record Revalidation
An informational message the submitter will receive when your Medicare enrollment record is due to revalidation.
PVNF Your Medicare enrollment record is due for revalidation. Failure to respond may result in a hold on payments and possible deactivation of your enrollment. (PVNF) Enrollment Record Revalidation
An informational message the submitter will receive when your Medicare enrollment record is due to revalidation.

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