J15 Part A Claims Processing Issues Log
Listed below are current system-related claims processing issues that have been reported to the Centers for Medicare & Medicaid Services (CMS) and/or the Fiscal Intermediary Standard System (FISS) Maintainer. This information is made available and updated as we have new information or updates to share, so you may review prior to contacting the Part A Provider Contact Center. A list of resolved issues is also available at the end of this list. If you still have questions, please call 866.590.6703.
|Reason Code/Status Location
|Reason Code C7251
||Claims are denying in error stating that services were within a Skilled Nursing Facility (SNF) stay when there is no SNF stay indicated on the Common Working File (CWF).
The CWF has responded that reason code C7251 is setting when a prior SNF claim has discharge status of 30 (still a patient) on the claim. The prior claim will need to be corrected to indicate the correct discharge status code before the claim receiving C7251 can process.
CGS is still actively working with the CWF to resolve the issue.
|Reason Code C7252
||Claims are denying or being recouped in error because of incorrect editing at the CWF.
CGS has implemented a correction for claims rejected incorrectly for reason code C7252 as of June 14, 2016. Claims rejected with C7252 in error prior to June 14, 2016 will be adjusted by CGS to pay correctly. Adjustments should be completed by mid-September.
CGS will create a work-around in FISS to override the C7252 response for lines containing revenue code 0510 and HCPCS G0463. CGS will also adjust claims denied in error.
CGS is aware of the issue and is communicating with the Fiscal Intermediary Standard System (FISS) maintainer and the CWF to resolve the issue.
|Reason Codes 59182, 59183, 59112-59115
||CMS and CGS are aware that some claims may be denying incorrectly in relation to NCD 20.4 with the listed reason codes.
The issue has been resolved and all suspended claims have been released.
CGS will suspend the potential affected claims to location SM5DEF until the issue has been resolved. These claims will be set to suspend to prevent the claims from continuing to deny in error. Once the edit is working correctly, CGS will release the suspended claims so that they will edit with the corrected logic.
If your claims have denied with one of the reason codes, and you are unsure whether it denied incorrectly, you are advised to submit an appeal.
|Certain claims that include a covered ICD-10 diagnosis code based on the LCD were medically denied in error with reason code 55503.
||Some examples of medically reviewed claims denied in error are mammography, sleep study, CT, MRI, vascular study, speech language pathology, and bone mass measurement claims.
When using the appeals process, ensure that you submit records/documentation with your appeal.
Adjustments to the following types of claims which denied incorrectly for the LCD have been completed:
Should you have claims with denials that were not adjusted and you disagree with the denial, please follow the appeals process.
- Sleep Studies
- Bone Mass Measurement
- Vascular Studies
CGS continues to work diligently to review the remainder of our LCDs. CGS advises providers to not let their appeal rights expire if they disagree with any denial.
CGS is in the process of adjusting claims that denied in error prior to 03.01.16. Claims received after 03.01.16 will need to be appealed if providers disagree with the denial.
Reminder: The correct use of an ICD-10-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the determination.
CGS is aware that there continues to be issues with claims and adjustments denying incorrectly with reason code 55503. Internal discussions are ongoing. Any additional information or resolutions will be communicated via this CPIL as it is received.
CGS has completed the LCD edit revalidation, and expects all adjustments to correct the incorrectly denied services to be completed by March 1, 2016.
If providers see any denials after March 1, 2016, they should follow the appeals process as all LCD edits have been revalidated.
Additional mammography claims that were medically denied in error have been identified and are being adjusted.
The vascular study adjustments have been completed and are being verified.
CGS has reviewed all LCD edits and the edits are being revalidated. Remaining claims that were medically denied in error will be adjusted by the end of February 2016.
Again, as a reminder, contact the PCC if you are unsure if the denials are in error. Use the appeals process if you are unsure to prevent the timeframe expiring.
Affected mammography claims have been adjusted. Other affected LCDs and claims that may have been affected are still being actively researched.
As a reminder, contact the PCC if you are unsure if the denials are in error. Use the appeals process if you are unsure to prevent the timeframe expiring.
Medically reviewed claims denied in error are still being adjusted. As a reminder, contact the PCC if you are unsure if the denials are in error, and use the appeals process if needed.
This issue has been corrected and claims denied in error will be adjusted. All other medical denied claims will need to be appealed as usual.
Adjustments will begin processing the week of November 23rd.
If providers are unsure if their denials are due to the issue or not, please contact the PCC to verify.
If a specific ICD-10 diagnosis is not listed on an LCD, and providers believe it should be, email CMD.Inquiry@CGSAdmin.com. These inquiries will be reviewed on a case by case basis and a response will be received from the CMD Inquiry.