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 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

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.

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.
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 website.
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.
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.
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.

Print | Bookmark | Email | Font Size: + | –

Resolving Rejected Home Health Claims Caused by Billing Errors

Home health claims most often reject because the claim is a duplicate of one already submitted, or the beneficiary information on the claim does not match the eligibility record at the Common Working File (CWF). When a claim rejects (status/location R B9997), home health agency (HHA) providers may be able to resolve the billing error by resubmitting a new claim, electronically adjusting, or submitting a paper claim adjustment. See the "Adjustments/Cancels" web page for additional information on adjusting Medicare claims.

Tips for Avoiding Claims from Rejecting

Always check a beneficiary's eligibility using the ELGH or ELGA eligibility systems prior to admission and billing Medicare. Access Chapter 2 - Checking Beneficiary Eligibilityof the Fiscal Intermediary Standard System (FISS) Guide for more information about verifying eligibility information for Medicare beneficiaries. For information about other systems available for checking eligibility, refer to the "Checking Beneficiary Eligibility" web page on the CGS website.
Review the reason codes 38031, 38157 and 38200 by accessing the Reason Code Search and Resolution Web page and type the code to display information about avoiding duplicate billing errors.

Top

Resubmitting a New Claim

If the claim information did not post to the CWF, submit a new claim with corrected information. Typically, home health claims that overlap a beneficiary's hospice election or a Medicare Advantage (MA) Plan enrollment period do not post information to CWF when they reject.

For more information about the beneficiaries who receive simultaneous home health and hospice services, see the Election of the Medicare Hospice Benefit While Receiving Home Health Services and access the Reason Code Search and Resolution webpage and type the C7010 reason code for details.
For more information about MA Plan enrollment periods and home health beneficiaries, see the Medicare Advantage (MA) Plans — Claim Filing Tips and access the Reason Code Search and Resolution Web page and type the U5233 or 7CS21 reason code for details.

To verify whether the rejected home health claim posted to episode information to CWF, review the information in the TPE-TO-TPE (tape-to-tape) field, which can be viewed on the FISS MAP171D screen. To access this screen:

Log on to FISS
At the Main Menu screen, enter "01" and press <ENTER>
At the Inquiry Menu screen, enter "12" and press <ENTER>
At the Claim Summary Inquiry screen, type your National Provider Identifier (NPI) in the NPI field, the beneficiary's Medicare ID number in the HIC field, and FISS status/location R B9997 in the S/LOC field and press <ENTER>. You may also want to type the claim's "FROM DATE" and "TO DATE" to narrow your search.
Any claims that match your search criteria will appear. Select the rejected claim you are researching by typing an "S" in the SEL field next to the Medicare ID number of the claim and press <ENTER>.
FISS Page 01 will appear. Press the F8 key to move forward to FISS Page 02.
Press the F2 key to access MAP171D.

The letter "X" in the TPE-TO-TPE field in the screenprint below indicates that the original rejected claim data did not post to the CWF. Therefore, a new claim with the correct information can be resubmitted to Medicare.

screenshot

Note: Prior to resubmitting the new home health claim, check to ensure that your Request for Anticipated Payment (RAP) didn't auto-cancel. See the Avoiding Reason Code 38107quick resource tool for information on how to determine if a RAP auto-canceled.

Top

Electronically Adjusting a Rejected Claim

If the original claim information has posted to the CWF (TPE-TO-TPE field is blank), you will need to adjust the original claim. Resubmitting a new claim may cause the claim to reject as a duplicate.

Typically, home health claims that overlap the dates of service a beneficiary was in an inpatient stay or are impacted by an open Medicare Secondary Payer (MSP) record post information to CWF when they reject and therefore, must be adjusted.

For more information about home health claims that reject due to overlapping an inpatient stay, see the reason code C7080 information by accessing the Reason Code Search and Resolution Web page and type the code to access details.
For more information about submitting MSP information on home health claim adjustments, see the Medicare Secondary Payer (MSP) Billing & Adjustmentsquick resource tool.
- Note that MSP situations where the services are related to a no-fault, liability or workers' compensation (WC) record, and the primary insurer was billed, but no response was received from the insurer may not be adjusted electronically.
- MSP situations where you are reporting a payment from the primary payer may not be adjusted electronically using FISS.

Detailed instructions on submitting electronic adjustments to rejected claims using FISS Option 33 are available in Chapter 5- Claims Correctionof the Fiscal Intermediary Standard System (FISS) Guide. Because the rejected claim posted the episode information out on CWF, HHAs should not submit a new Request for Anticipated Payment (RAP) for the episode prior to submitting the adjustment.

REMINDER: When claims reject, charges are placed into the "NCOV CHARGES" (non-covered charges) field on FISS Page 02. When using FISS for online adjustments, all revenue lines showing information in the "NCOV CHARGES" field must be deleted and added back by re-entering the revenue code, HCPCS, units, charges, and service date information in new detail lines. See Chapter 5- Claims Correctionof the Fiscal Intermediary Standard System (FISS) Guide for instructions on deleting and adding revenue code lines.

If you are trying to adjust a rejected claim electronically using FISS, and no information appears when you select the claim using Option 33, look for a message at the bottom of FISS Page 01 that states "ADJUSTMENT CLAIM IS ALREADY CANCELED". When this occurs, the claim cannot be adjusted. Instead, a new claim should be submitted to CGS with the changed information.

Top

Submitting a Paper Claim Adjustment

In the rare circumstance that an electronic adjustment is not possible, the alternative option is to submit a paper adjustment (UB-04). Because the rejected claim posted the episode information out on CWF, HHAs should not submit a new Request for Anticipated Payment (RAP) for the episode prior to submitting the adjustment.

Review the following tips to ensure the paper adjustment is not sent back to you for correction:

Submit the correct type of bill (TOB) in FL 4. The third position of an adjustment TOB must be a "7" (327). Ensure you are reviewing the second digit of the TOB for the rejected claim (320) to correctly submit the adjustment TOB.
Ensure that a Claim Change Reason Code (CCRC) appears in the first available Condition Codes field (FL 18-28). A listing of CCRCs used for claims adjustment is available in Chapter 5- Claims Correctionof the Fiscal Intermediary Standard System (FISS) Guide.
Enter the Document Control Number (DCN) of the rejected claim in FL 64 of the paper claim form. This information can be found in the "DCN" field on MAP171D or on the Remittance Advice (RA) you received when the claim rejected. Review the instructions above in the Resubmitting a New Claim section of this webpage for accessing MAP171D of the rejected claim. See the screenprint below that indicates where the DCN field on MAP171D is located
Explain why you are submitting the paper adjustment in the Remarks field (FL 80).