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: + | –

Pre-Claim Review Demonstration for Home Health Services

Update: As of April 1, 2017, the Pre-Claim Review demonstration will be paused for at least 30 days in Illinois. The demonstration will not expand to Florida on April 1, 2017. Refer to the CMS Pre-Claim Review Demonstration for Home Health Services Web page for additional information.

The Centers for Medicare & Medicaid Services (CMS) is implementing a three year pre-claim review (PCR) demonstration program for home health services provided to beneficiaries in Illinois, Florida, Texas, Massachusetts, and Michigan. This demonstration includes rendering providers who are located in the demonstration states regardless of from where they bill.

The PCR program ensures that the Medicare home health benefit coverage criteria are met. Refer to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7, §30.5.1.1for information on home health coverage criteria. For additional information on the home health PCR program, visit the Pre-Claim Review Demonstration for Home Health Services information and the Pre-Claim Review Demonstration for Home Health Services Operational Guide on the Centers for Medicare & Medicaid Services (CSM) website.

The start date in the following chart applies to episodes of care that begin on or after the PCR start date. A PCR must be submitted for each 60 day episode. Home health providers may begin submitting PCR requests two weeks prior to the start date. Note the receipt date for purposes of processing and timeliness is considered to be the start date of the demonstration. To check to see if your home health agency is part of the PCR demonstration, refer to the CGS Home Health Pre-Claim Review Demonstration Look-Up Tool.

State	Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN) – State Codes	Start Date (for episodes with a start date on or after)	Two Weeks Prior
Illinois	14 and 78	August 3, 2016	Paused as of April 1, 2017
Florida	10, 68 and 69	TBD	TBD
Texas	45, 67, 74, and 97	TBD but no earlier than December 1, 2016	TBD
Massachusetts	22 and 82	TBD but no earlier than January 1, 2017	TBD
Michigan	23	TBD but no earlier than January 1, 2017	TBD

Refer to the Certification Number (CCN) State Codes Memorandum for additional information about the CCN.

Note: If a final claim is submitted without a PCR request it will be stopped for pre-payment review. The provider will receive an Additional Development Request (ADR) and the CGS Medical Review will perform a pre-payment review. In addition, after the first three months from the start date of the PCR review demonstration, for each claim that does not have a PCR request submitted, a 25 percent reduction will apply to the full amount of the claim. The 25 percent reduction is not subject to appeal, and cannot be billed to the beneficiary.

Providers under Unified Program Integrity Contractor (UPIC) review and Program Safeguard Contractors (PSC) review are not eligible to submit pre-claim review requests.

Note: The PCR program does not apply to Requests for Anticipated Payment (RAPs), Low Utilization Payment Adjustments (LUPAs), demand bills with condition code 20, and no-pay bills with condition code 21.

Refer to the four steps below detailing the PCR process.

Step 1 – Submit RAP
Step 2 – Complete/Submit PCR Coversheet and Documentation
Step 3 – Medical Review of Documentation and Decision Notification
Step 4 (Conditional) – Resubmitting PCR Requests
Step 5 – Submit Final Claim

Top

Step 1 – Submit RAP

There are no changes related to submitting the Request for Anticipated Payment (RAP), or to the RAP payment. Submit the RAP when appropriate conditions are met (Medicare Claims Processing Manual, Pub. 100-04, Ch. 10, section 10.1.10.3).

A PCR request must be submitted for each 60-day episode.

Top

Step 2 – Complete/Submit PCR Coversheet and Documentation

A PCR request should be submitted when you have obtained all required documentation from the medical record to support medical necessity and demonstrate eligibility requirements are met. The PCR process must occur before the final claim is submitted for payment.

Complete the Pre Claim Request (PCR) Coversheet (temporarily unavailable) and submit with the following supporting medical documentation.

IMPORTANT NOTE: It is important that providers complete the Pre Claim Request (PCR) Coversheet in full. List all HCPCS codes that will be submitted on the final claim.

Certification and/or Recertification
Face-to-Face visit note
Acute/post-acute care visit notes
Home health plan of care (signed and dated)
Therapy evaluations
Outcome and Assessment Information Set (OASIS)
Initial orders

The following type of bills (TOBs) and HCPCS codes are part of this PCR program:

TOBs

327 – Replacement of prior claim
329 – Final claim for home health episode
32Q – Reopening request

The following TOBs apply to adjustments initiated by CGS.

32F

32G

32H

32I

32J

32K

32M

32P

HCPCS (codes subject to change)

Skilled Nursing	G0162, G0163, G0164, G0299, G0300, G0493, G0494, G0495, G0496 NOTE: G0163 and G0164 are not valid for visits on or after January 1, 2017. HCPCS codes G0493, G0494, G0495, G0496 are valid for visits on or after January 1, 2017.
Physical Therapy	G0151, G0157, G0159
Occupational Therapy	G0152, G0158, G0160
Speech-language Pathologist	G0153, G0161
Social Worker	G0155
Aide	G0156

How to Submit: The PCR Coversheet and documentation can be submitted via :

Fax 615.664.5950
myCGS Web Portal – Refer to Chapter 7: Forms Tabof the myCGS User Guide for details. For more information about myCGS and how to register, refer to the Chapter 1: Overview of myCGS of the myCGS User Guide.

NOTE: For PCRs submitted via myCGS, the PCR decision notification letter (provisionally affirm or non-affirm) will be sent to home health providers via mail or fax. When submitting a PCR request, via myCGS, please provide your fax number in the space indicated on the PCR Coversheet. If no fax information is provided, CGS will mail the PCR decision notification letter to the provider.
esMD (Electronic Submission of Medical Documentation) – Refer to the CMS "Information for Providers" Web page for details.

Mail:
CGS Administrators
PO Box 20203
Nashville, TN 37202

Future enhancements are planned which will allow submission via Electronic Submission of Medical Documentation (esMD).

Top

Step 3 – Medical Review of Documentation and Decision Notification

CGS Medical Review staff will review the PCR request and documentation. A decision letter (provisionally affirm or non-affirm) will be sent to the HHA and the beneficiary within 10 business days of receipt for an initial request. If non-affirmed, the letter will provide a detailed explanation of the requirements not met. Refer to the Additional Resources section below to access the provisionally affirm/non-Affirm provider and beneficiary letter Job Aids.

Note: When the PCR is faxed or mailed to CGS, the decision letter will be sent in the same manner to the provider. If the PCR request is submitted via the myCGS secure web portal, at this time, the PCR decision notification letter will be sent to home health providers via mail or fax (see Step 2).

Affirm decisions mean that Medicare coverage, coding, and payment requirements have been met.
Non-affirm decisions mean that the submitted documentation did not meet Medicare requirements for coverage.
- Non-affirmed decisions are considered an initial payment decision and the standard claims appeal rights apply. Refer to the "Appeals Overview" Web page for additional information.
Resubmitted PCR Requests
- An unlimited number of resubmissions are allowed. Refer to Step 4 (below) for information about resubmitted PCR requests.
Unique Track Number (UTN)
- The decision letter (affirm and non-affirm) will include a 14 digit Unique Tracking Number (UTN), which must be submitted on the final claim.

Top

Step 4 (Conditional) - Resubmitting PCR Requests

Resubmitted PCR requests may be submitted only after the previously submitted request and documentation are reviewed by Medical Review and you have received a non-affirmed decision notification letter. When a non-affirm decision is made, and based on the decision letter, additional medical documentation is available that will correct the deficiencies, a resubmitted PCR may be submitted. An unlimited number of resubmissions are allowed. A resubmitted PCR request can not be submitted after the final claim has been submitted.

The resubmitted PCR request should include the PCR Coversheet, completed in full with all the services (HCPCS) provided, and the initial documentation originally submitted and any additional documentation. Be sure to check the "Subsequent Request" check box on the PCR Coversheet.

Upon receipt, CGS will review the PCR request and documentation. A decision letter (affirm or non-affirm) will be sent to the HHA and the beneficiary within 20 business days.

Top

Step 5 – Submit Final Claim

Submit the final with the usual data elements. Refer to the "Home Health Claims Filing" Web page for additional information.

Note: The PCR demonstration does not apply to Requests for Anticipated Payment (RAPs), Low Utilization Payment Adjustments (LUPAs), demand bills with condition code 20, and no-pay bills with condition code 21.

In addition to the usual data elements, the 14-digit Unique Tracking Number (UTN), which is provided in the PCR decision letter, must be reported as follows.

ASC X12 837 5010 – Positions 19 through 32 of Loop 2300 REF02 (REF01=G1)
CMS-1450 (UB-04) – Form Locator 63 (positions 19-30). The last two characters of the UTN should be written outside the lines next to position 30.
Direct Data Entry – TREAT. AUTH. CODE field immediately following the 18-digit OASIS Matching Key code (example below).

Final claims will process based on the decision provided in the pre-claim review notification letter. If the notification letter indicated an affirm decision, the final claim will process and pay as long as all other technical and Medicare requirements are met upon claim submission. If the notification letter indicated a non-affirm decision, the final claim will be denied. Traditional appeal rights apply to non-affirmed denials.

Top

Additional Resources:

Top

Updated 04.03.17