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 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.
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.
||CGS identified an issue that caused some MolDX claims to inappropriately suspend for review with reason code 58888.
This issue has been resolved. Claims currently suspended to this location that do not contain a MolDX ID in the remarks field will be reviewed to ensure coverage criteria is met. Claims that have suspended incorrectly are being released.
|Skilled Nursing Facility (SNF) are not pricing correctly on or after 10.01.15 date of service.
||CGS has received clarification from CMS and the SNF Provider Specific Files are being updated.
Due to the volume of claims requiring adjustments, CGS is still in the process of adjusting the affected claims.
All updates have been completed as of mid-December, 2015. Affected claims are currently in the process of being adjusted, with an anticipated completion date of mid-February.
Once the update is completed, SNF claims that paid incorrectly will be adjusted.
|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.
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.
|Healthcare Common Procedure Coding System (HCPCS) codes C9453, C2623, C9449, C9450, C9454, and C9455.
||Claims are systematically being RTP'd in error with reason code 32402, and/or 32404.
Files have been corrected and/or updated as of January 27, 2016. If you have claims with HCPCS that have RTP'd for this reason, F9 or resubmit the claim(s). If you have omitted the HCPCS because the file was not correct, adjust the claim and add the HCPCS.
CGS is actively updating affected files. Once the files are updated, CGS will notify providers via this CPIL. When charges are submitted after the correction has been made, indicate in Remarks section of the claim that the timeliness is due to a file issue, if the claim is not timely.
There are ongoing issues with some HCPCS in certain regions. The CPIL will be updated once the issue is resolved. 10.20.2015
The issue has been resolved for claims in the KY and OH region for HCPCS C9453. The issue has been resolved for claims in the KY region for HCPCS C2623.
Providers may F9 or resubmit claims that are RTP'd in error for these HCPCS/regions. Once the issue is resolved for HCPCS C2623 for the OH region, the CPIL will be updated and providers may F9 or resubmit those claims.
||CGS has identified an issue with Medical Review claims suspending incorrectly in the system.
Suspended claims in this location are still actively being processed, and the volume has been reduced significantly.
Claims suspended in SM5KEY are still actively being worked.
Claims suspended in SM5KEY are actively being adjudicated. We are anticipating the claims will be worked to a current status by November 13, 2015, or sooner.
A resolution has been determined and claims will be released within 30 days.
|36602, 36381 Status Location SMG279
||HCPCS code G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral) is not pricing when submitted on claims.
CGS is in the process of adjusting claims affected by this issue.
It has been determined that the July release will not fully correct the problems associated with the claims. CMS has instructed CGS to release the held claims, process them and append condition code 15. When the correction is implemented in January 2016, the claims will be adjusted to process and pay correctly.
A tentative correction date is scheduled when the July release is implemented. Suspended claims will be released to process.
There are still issues with pricing of the codes.
There are ongoing issues with the pricing of the codes. CMS has advised contractors to continue to hold claims until further notice.
Claims with HCPCS codes G0279 or G0280 will be suspended in location SMG279 and SMG280 until the FISS April Quarterly Release, scheduled to go into production on 04.06.15, is implemented. There is no workaround. Once the release is implemented, suspended claims will be released by CGS.