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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.

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

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.

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.

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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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  4. 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.
  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.

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.


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Medical Review Additional Development Request (ADR) Process Prepayment Review

WHAT IS AN MR ADR? – When a claim is selected for medical review, a medical review additional development request (MR ADR) is generated requesting medical documentation be submitted to ensure payment is appropriate. Documentation must be received by CGS within 45 calendar days for review and payment determination.

WHY AN MR ADR? – Any claim submitted to CGS may be selected for medical review and generate an MR ADR. Claims may be selected when elements on the claim match the parameters of a pre-payment edit established by CGS. Additional information about the types of edits, and a current list of widespread edits, can be accessed from the "Overview of Medical Review" Web page.

The information below will help ensure that necessary steps are taken to submit documentation timely and avoid having claims denied as a result the MR ADR process.

CHECKING FOR MR ADRs USING FISS – When a claim is selected for an MR ADR, the claim is moved to a Fiscal Intermediary Standard System (FISS) status/location S B6001. Providers are encouraged to use FISS Option 12 (Claim Inquiry) to check for ADRs at least once per week. You will not receive any other form of notification for an ADR.

Your agency should have an internal process established to monitor claims selected for an ADR, and to ensure the documentation is submitted within the required timeframe. If the requested documentation is not received timely by CGS, the claim will be automatically denied.

To check for MR ADRs using FISS Option 12, key your NPI number, the status/location 'S B6001', and press Enter. Claims selected for MR ADR will appear with reason code 39700.

ADR screenshot

FISS Pages 07 and 08 — Each claim that appears in S B6001 must be selected to identify the documentation that is being requested, as well as the timeframe by which the documentation must be received. This information is found on FISS Pages 07 and 08. These pages only appear when the claim is in status/location S B6001. Screen print FISS pages 07 and 08 for your reference. CGS requires FISS Page 07 be returned with the ADR documentation.

FISS page 07 includes the:

  • Medicare ID of the patient;
  • dates of service on the claim;
  • document control number (DCN) of the claim;
  • mailing address to which your documentation must be sent;
  • "Due Date", which is the 45th day. The requested documentation must be received by CGS on/before 45 calendar days of the request. According to the CMS Pub. 100-08, Ch. 3 §3.2.3.2External PDF) claims will be denied if the documentation is not received by day 46. Refer to the Additional Development Request Timeliness Calculator for assistance in determining the date ADR documentation must be received.

Example of FISS Page 07:

ADR screenshot

Press F6 to view the entire message. Press F5 to return to the beginning of FISS Page 07.

ADR screenshot

FISS Page 08 is a list of the documentation being requested. This may include initial assessments, the plan of care, physician's orders, visit notes, the certification of terminal illness and election statement (hospice), and OASIS assessments (home health). You may need to press F6 to view the complete list of requested documentation. In addition to the listed documentation, you should send any other documentation that supports payment of the services billed, even if the documentation is before or after the dates of service on the claim, but relevant to the services provided.

Example of FISS Page 08:

Screen shot

USING THE myCGS DASHBOARD TO CHECK FOR MR ADRs AND SUBMIT DOCUMENTATION

The myCGS MR Dashboard is another option for you to quickly identify whether you need to respond to medical review (MR) additional documentation requests (ADR).  Refer to the myCGS User Manual: Medical Review section for step by step instructions.

PREPARING YOUR DOCUMENTATION

When preparing your documentation, attach a copy of FISS Page 07 as the top page of your documentation to ensure the documentation is matched to the appropriate patient and claim.

If you are responding to multiple MR ADR requests, clearly separate the documentation for each claim. Due to CGS's process for imaging documentation, the use of rubber bands or binder clips, or mailing documentation for each claim in separate envelopes, is recommended. Multiple responses sent together, but not separated, may result in the documentation being imaged as one claim. Do not staple documentation.

CGS recommends providers organize the medical documentation in the order indicated below. This will assist CGS in reviewing your documentation more efficiently and will expedite the review process.

Providers should submit the necessary documentation to support the services for the billing period being reviewed. This may include documentation that is prior to the review period, such as admission records, hospice Interdisciplinary Group (IDG) review, etc.

Hospice ADR Checklist – Preferred Order

Home Health ADR Checklist – Preferred Order

  1. FISS Page 7 screenprint
  1. FISS Page 7 screenprint
  1. Signed election statement
  1. Physician Face-to-Face documentation

      a. Actual encounter note or progress note

      b. Discharge summary from inpatient stay

  1. Plan of care with physician certification/recertifications
  1. Plan of care with physician certification/recertifications
      a. If recertification, include initial certification
  1. Physician Face-to-Face documentation (for third and later benefit periods)
  1. Interim/verbal orders
  1. Physician orders
  1. OASIS assessment
  1. IDG reviews/POC updates

    Note: include reviews for each 15-day period to cover the billing period. This may include reviews/updates that occurred prior to the billing period.
  1. Nursing visit notes
  1. Admission initial assessment
  1. Therapy visit notes including evaluations/re-evaluations
  1. Visit notes (nursing, social worker, chaplain, etc.)
  1. Social work visit notes
  1. Physician visit notes
  1. Aide visit notes
  1. Other relevant documentation
  1. Other relevant documentation
    • a. Acute/post-acute care documentation to support home health eligibility.

Providers may include an outline or cover letter with their documentation. This can be used by CGS Medical Review staff as a roadmap and prove very helpful to highlight key dates or documentation that supports payment of the claim. However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter in order to be useful.

In addition, providers may use brackets, such as [ ] or { }, asterisks (*) or underlined text in the documentation to draw the reviewer's attention to important information. However, notations should not alter, or give the appearance of altering, the documentation. The use of a highlighter is not recommended.

SUBMITTING YOUR DOCUMENTATION

Documentation may be received by CGS either via US Mail, esMD, Fax, myCGS or on CD/DVD.

Submit your documentation so that it is received by CGS on/before 45 days ("DUE DATE" on FISS Page 07). Ensure that you allow ample time for mailing, and processing of the documentation when received.  This will prevent the claim from inadvertently denying. Mail to the address that appears on FISS Page 07:

CGS J15 MAC
J15 – HHH Correspondence
PO Box 20014
Nashville, TN 37202

NOTE: CGS does not recommend sending your documentation overnight via Fed Ex or UPS. If prompt mailing of your documentation is necessary to meet the due date, CGS recommends overnight delivery via the US Postal Service to the address above.  Using myCGS to submit your documentation is also an option.

myCGS is a free web portal that allows you to submit your ADR documentation directly to CGS and will help to ensure a timely response to an MR ADR. For more information on submitting MR ADR documentation via myCGS, refer to the myCGS User Manual: Forms information and the myCGS MR ADR Job Aid. myCGS also provides a secure message confirming receipt of the documentation, and a second message confirming it was accepted.

The Electronic Submission of Medical Documentation (esMD) process may be used as an alternative to mailing your documentation. For more information on the esMD process, refer to the CGS "Electronic Submission of Medical Documentation" Web page.

CGS will also accept documentation submitted via Fax (1.615.660.5981).

RECEIPT OF DOCUMENTATION – When your documentation has been received by CGS, the claim is moved from status/location S B6001 to S M50MR for review. Providers can monitor the S M50MR status/location in FISS, to verify that their documentation has been received by CGS. Confirmation of receipt is also provided when using myCGS to submit your documentation.

REVIEW OF DOCUMENTATION – A CGS nurse reviewer will examine the medical records submitted to ensure the technical components (OASIS, certifications, election statement, etc.) are met, and that medical necessity is supported. CGS has 30 days from the date the documentation is received to review the documentation and make a payment determination. For demand denials (condition code 20), CGS has 60 days from the date the documentation is received to review the documentation.

A hierarchy is used to review documentation. This means that documentation is first reviewed for administrative documentation, and then medical documentation. Denials are applied according to the hierarchy; however, any additional findings will be addressed in the medical review findings notification.

Hospice Hierarchy   Home Health Hierarchy
Valid election statement Technical components: OASIS submission, certification/orders, FTF
Technical components: certification statement, FTF if 3rd or later benefit period Homebound documentation
POC updated every 15 days Intermittent skilled nursing or therapies
Disease acuity or trajectory supports 6 month prognosis – Hospice LCD: "Determining Terminal StatusExternal Website" Reasonable and medically necessary skilled service
Non-routine care supported Use "Physical Therapy – Home HealthExternal Website" LCD for guidance (when applicable)
Physician visits OASIS and coding

During the review, if a signature is found to be missing or illegible, or an electronic signature cannot be authenticated, the claim will be re-ADRd to you in status/location S B6001. Page 08 will show with edit 5ADR2 with a narrative indicating that additional documentation is required to support the signatures. Page 04 (Remarks) will specify the documentation being requested. The additional signature documentation must be received by CGS within 20 calendar days of the request. A screenprint of Page 07 should be attached to the top of the additional documentation and returned to CGS.

ADR OUTCOMES — Possible outcomes of the MR ADR include payment in full (P B9997), partial payment (P B9997), or a full denial (D B9997). Providers are notified of the payment determination via the FISS status/location, as well as their remittance advice. When a claim is denied with reason code 56900 indicating that the medical documentation was not received by CGS, or was not received timely, a "56900 reopening" may be requested within 120 days of denial to have the medical documentation reviewed by the Medical Review department, without utilizing the Medicare Appeals Process. All other denials for which the provider disagrees may be appealed using the Medicare Appeals Process.

ADR RESOURCES

Updated: 06.08.21

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