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.

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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.

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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.

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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

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May 11, 2021

Appeal Requests on Home Health Exceptions For an Untimely RAP

CGS has seen an increase of redeterminations, (1st level of appeal) being submitting without first requesting an exception for an untimely request for anticipated payment (RAP). A redetermination is not acceptable if an exception has not yet been submitted. When a redetermination requests is submitted without having an exception request, CGS will return the appeal request.

When a RAP is submitted untimely, the first step is to request an exception. To request an exception, submit the KX modifier on the final claim Health Insurance Prospective Payment System (HIPPS) code on the revenue code 0023 line. In addition, you must include information in the REMARKS field documenting how the following circumstances caused the RAP to be submitted untimely. If the information in the REMARKS field is not clear, a non-medical review additional development (non-MR ADR) request will be issued to obtain more information.

Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA's ability to operate
An event that produces a data filing problem due to a CMS or MAC systems issue that is beyond the control of the HHA
A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC
Other circumstances determined by the MAC or CMS to be beyond the control of the HHA.

If the final claim was submitted without the KX modifier, and you wish to request an exception, you may submit an adjustment (type of bill XX7) or a reopening request (type of bill (XXQ) and add the KX modifier and information in the REMARKS field.

Exception Request Outcome

When an exception is requested, and the review of the information provided in the REMARKS field, or the submitted documentation does not qualify for the exception to be granted, the penalty will still apply. At that point, the home health agency may appeal the penalty amount applied to the final claim. Refer to the 1st Level of Appeal – Redetermination web page for additional information.

Resources:

What You Need to Know About the Home Health RAP Penalty, CGS article
MM11855, Penalty for Delayed Request for Anticipated Payment (RAP) Submission – Implementation.
Submitting a Final Claim under the Home Health Patient-Driven Groupings Model CGS web page
1st Level of Appeal – Redetermination CGS web page