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

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

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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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Resolved Fiscal Intermediary Standard System Claims Processing Issues

Updated: 07.20.18

Date Closed

Description of Issue

07.06.2018

The MAS (Medicare Appeals System), used to effectuate favorable and partially favorable Appeals, is not working appropriately to allow some claims to process and pay.

07.06.2018

The reason code 37253 cannot be bypassed for claims that are submitted with the 'DR' condition code (CC) indicating a waiver under §1135 of the Social Security Act.

06.04.2018

Claims that were originally submitted for processing with a Health Insurance Claim Number (HICN) as the beneficiary identifier are being incorrectly displayed in Direct Data Entry (DDE) with the Medicare Beneficiary Identifier (MBI). Claims should be displaying in DDE with the original identifier submitted on the claim (either the HICN or MBI).

05.21.2018

Type of bill 3XG PEP adjustments caused a negative amount in Value Code 17 which caused overpayments to display on the Summary page of the remittance advice in the Adjustment to Balance Field.

05.07.2018

(Home Health) – Some home health claims and adjustments are cycling in FISS in status/location S M90H4 with reason codes E0419, V8029, V8030, and V8031.

The issue involving some adjustments (type of bill XXG), continues as previously reported. Refer to the "Resolved Fiscal Intermediary Standard System (FISS) Issues" web page for details.

03.08.2018

Requests for Anticipated Payments (RAPs) are suspending in status/location S M90CW with reason code E61#H.

02.12.2018

The Interactive Voice Response (IVR) system is not calculating the QMB deductible and coinsurance amounts correctly.

02.19.2018

CGS is aware that some adjustments continue to pay the incorrect 60 day 'high' and 'low' Routine Home Care rate

02.06.2018

Payers secondary to Medicare aren't able to process some of your direct billed claims due to patient responsibility deductible and coinsurance amounts on the Medicare Remittance Advice (RA) showing zero. Claims automatically crossed over from Medicare to secondary payers aren't impacted.

02.12.2018

When a hospice Notice of Election (NOE) is submitted via EDI, effective with CR 10064, the data included in the non-required Patient Status and Source fields is not being removed and is causing the NOE to suspend with reason code E2101.

02.12.2018

The Companion Guide created by CMS included the use of the procedure code Q5009 (not otherwise specified code). This required a description in the service line (data element SV202-7); however, this information was not identified as being required in the Companion Guide. As a result, NOEs received without the procedure code description data element will reject in the EDI front-end editing and will be returned via the 277 Claims Acknowledgement Transaction.

01.22.2018

Billing transactions submitted with reopening Type of Bill (TOB) 8XQ are receiving reason code 31411 indicating the occurrence span code 77 is not valid.

01.22.2018

Home health claims (32X; excluding 322) with the valid physician specialty codes 18 or 72 are being incorrectly denied with reason code 32072.

12.14.2017

An issue has been identified with the 60 day 'high' and 'low' Routine Home Care rate being applied incorrectly with dates of service on or after January 1, 2016.

12.11.2017

Negative Pressure Wound Therapy (NPWT) claims billed on a 34X Type of Bill (TOB) are going to the Return to Provider (RTP) incorrectly with reason code 38054.

12.11.2017

Home health and hospice claims and Requests for Anticipated Payment (RAPs) are being rejected in error.

09.26.2017

Home health no-payment claims submitted with condition code 21 are being denied in error with an incorrect reason code (37253 – no OASIS assessment found). No payment claims do not require an OASIS assessment.

Reason Code/Status Location	Situation	Status
E94G2 Status/location S M90PP	2/21/2017 (Home Health and Hospice) – Some home health and hospice claims are suspending with reason code E94G2 in status/location S M90PP. FISS is incorrectly applying the reject reason code 32352 and changing the type of bill from 329 to 320.	5/30/2017 – The research done by the CGS Technical team indicated that the E94G2 is not a system issue. Appropriate No-Pay codes will be applied as necessary and the claims will be recycled to continue processing. No action by providers is necessary. 2/21/2017 – (Updated 03/28/2017) The CGS Technical team is researching this issue. CGS Claims staff are manually working the claims to continue processing. Please note, according to the Medicare Claims Processing Manual (Pub. 100-04, Ch. 1, §80.2.1.1) Medicare contractors have 30 days to process clean claims. In the event that claims cannot be processed within 30 days, claims will be paid with interest.
U5601 Return to Provider (RTP) file, T B9997	12/15/2016 (Hospice) – When a hospice claim for pneumococcal pneumonia and influenza vaccine is processed, the monthly claim including hospice services is incorrectly going to the Return to Provider (RTP) file with reason code U5601 indicating the dates of service overlap a previously processed claim.	2/14/2017 – This issue has been resolved. Providers may submit any flu claims that they may be holding. 12/15/2016 – The Centers for Medicare and Medicaid Services (CMS) and the Common Working File (CWF) are aware of this issue. If your monthly hospice claim is in RTP with reason code U5601 because your vaccination claim has processed, you may cancel (XX8) the vaccination claim. Once canceled, you may F9 the monthly hospice claim from the RTP file to continue processing. CGS recommends hospices hold their vaccination claims at this time. However, after the monthly hospice claim processes, you may resubmit the vaccine claim and they will be held in status/location SMFLUH until this issue is resolved.
32403 and 32404 Status/location S MFEE4 or in the Return to Provider (RTP) file, T B9997	1/20/2017 (Home Health) – Home health claims that span 2016 and 2017 dates of service, with line item dates of service prior to 1/1/2017 with HCPCS code G0163 or G0164 are incorrectly receiving reason code 32403. HCPCS G0163 and G0164 were retired and are no longer valid for services on or after 1/1/2017; however, they are valid for line item service dates prior to 1/1/2017.	2/1/2017 – This issue has been resolved. Claims suspended in status/location S MFEE4, S MFEES, and S MHCPC will be released to cycle through FISS to continue processing. If you have claims in the Return to Provider (RTP) file related to this issue, press F9 to release the claim to continue processing. 1/20/2017 – This issue has been reported to the FISS maintainer.
U5112 Status/location S MU511	10/27/16 (Hospice) – Reason code U5112 is being applied to hospice claims incorrectly.	12/01/16 – The resolution to this issue was implemented on November 21, 2016. Claims are no longer receiving reason code U5211 in error. If you see a claim, other than a NOTR (8XB), in RTP with reason code U5211 after November 21st, please contact the Provider Contact Center. 10/27/16 – The system maintainer is aware of the issue and a resolution is scheduled for production on November 21, 2016.
36458 RTP status / location T B9997	10/27/16 (Hospice) – Some hospice claims with dates of service on or after October 1, 2016, are incorrectly being returned to provider (RTP) indicating that the Core-Based Statistical Area (CBSA) Number is invalid.	11/9/16 – CMS has provided instructions to implement a temporary fix that will allow claims to process. If providers have claims in the RTP file with reason code 36458, please F9 the claim(s) to allow continued processing. 10/27/16 – This issue has been reported and is currently being researched by the system maintainer.
NA	2/2/16 (Hospice) – Hospice claims with dates of service on or after January 1, 2016, may be receiving incorrect Service Intensity Add-on (SIA) payments.	4/19/2016 – CGS has completed the adjustments to correct the SIA payments. 3/2/2016 – The scheduled system release has been implemented. CGS anticipates that CMS will instruct us to adjust these claims to correct payment; however, providers may proceed with submitting adjustments to the claims. 2/2/16 – The FISS maintainers have scheduled a system release for February 22, 2016, to resolve this issue.
NA	1/8/2016 (Home Health) – The Integrated Outpatient Code Editor (I/OCE) is adding 10 payer only value codes (QN – QW) on home health claims that are received on or after January 1 2016.	4/19/2016 – This issue has been resolved by the implementation of the April 2016 quarterly release. Please note, that if you adjust a claim that includes the additional 10 value codes (QN – QW), you will need to remove the value codes and the zero amounts from your adjustment. 1/8/2016 – The Centers for Medicare & Medicaid Services (CMS) is aware of this issue. This issue will be resolved with corrected I/OCE logic, which is scheduled for implementation in the April 2016 quarterly release.
NA	2/2/16 (Home Health) – The HIPPS codes on home health claims with 2015 to current dates of service and 20 or more therapy visits, are recoding incorrectly. The 2nd and 3rd positions of the HIPPS code are being changed when the HIPPS code begins with a 5.	5/6/2016 – CGS has completed all the adjustments related to this issue. The adjustments will process through FISS as usual. 4/19/2016 – CMS issued the MLN Matters® article, MM9608 indicating that this issue will be resolved with the April 25, 2016, implementation of a revised HH Pricer. CGS will adjust home health claims to correct payments. 3/2/2016 – Upon researching this issue, it was identified that there is an issue with pricing home health claims with HIPPS recoding from a 5 to a 5. 2/2/2016 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS) for research.
E0419 Status/location S M90H4	8/19/2015 (Home Health) – It appears that the issue involving some adjustments (type of bill XXG), was not resolved as previously reported.	2/5/2016 – A resolution to this issue has been implemented. CGS is working to release claims suspended in status/location S M90H4 with reason code E0419. No action by providers is required. 12/1/2015 – The standard system maintainer has indicated the resolution scheduled for November 23, 2015, did not resolve this issue. An additional system update will be necessary and is currently being researched. 10/23/2015 – A resolution to this issue is scheduled for implementation on November 23, 2015. 8/19/2015 – This issue has been reported to the FISS technical staff for additional research.
	11/9/2015 (Home Health) – Some home health claims are processing with the incorrect HIPPS code due to the HIPPS code not recoding correctly.	1/26/2016 – The necessary adjustments are being made and are expected to process in mid-February. If you have a claim that you feel should have been adjusted but was not, please contact the Provider Contact Center (PCC) at 1.877.299.4500 (Option 1). 12/17/2015 – A resolution to this issue will be implemented January 4, 2016. CGS will make the necessary adjustments to claims/adjustments with receipt dates between 10/1/2015 and 1/4/2016 and a provider submitted HIPPS code of 5, and fewer than 20 occurrences of therapy visits (042x, 043x, and 044x). Home health agencies do not need to take any action. These adjustments will be completed within two months of the January 4, 2016, implementation date. 11/9/2015 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS) and to the FISS maintainer.
32402 and 32403 Status/location S MFEES	1/28/16 (Home Health and Hospice) – Home Health and Hospice claims are receiving reason code 32402 and/or 32403 incorrectly when the claim includes the HCPC code G0154, G0299, and G0300	1/28/16 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS). 2/2/16 – CMS has provided instructions for CGS to update the HCPC file. This update has been completed, and CGS staff will work to release affected claims from the S MFEES status/location to continue processing. If you have claims in the Return to Provider (RTP) related to this issue, please F9 the claims to allow processing.

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