LICENSES AND NOTICES

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.

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.

  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.
  3. 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.
  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.


Corporate

Print | Bookmark | Email | Font Size: + |

J15 Part A Resolved Claims Issues

Updated: 06.24.21

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.15.2021

Closed

Outpatient Hospital (13X TOB)

Claims for non-invasive vascular studies with dates of service 11.02.2020 – 01.10.2021 may have denied with reason code 53988 in error.

53988

A56697 – Billing and Coding: Non-Invasive Vascular StudiesExternal Website

02.15.2021

Updates

03.29.2021 – Claim adjustments were completed as of 02.15.2021.

MAC Action

01.21.2021 – CGS will identify and adjust claims denied in error.

Provider Action

01.21.2021 – No action required.

Proposed Resolution

01.21.2021 – CGS corrected the system edit on 01.11.2021.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.20.2021

Closed

Part A Providers

We issued some Part A Medical Review post-payment decision letters with an incorrect estimated overpayment amount. The letters were issued for claims denied with reason code 56900 (requested records not received).

56900

NA

01.20.2021

Updates

01.20.2021 – This issue has been resolved.

MAC Action

01.08.2021 – Once the issue is resolved, CGS will send a letter with the correct estimated overpayment amount for all lines on the claim.

Provider Action
Proposed Resolution

01.08.2021 – CGS is researching to resolve the issue.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.11.2021

Closed

Part A Hospital OPDs

Some Part A hospital Outpatient Department (OPD) prior authorization decision letters were issued with digits 4-7 of the MBI populated in the last four digits of the beneficiary's MBI.

NA

NA

01.11.2021

Updates
MAC Action

01.11.2021 – CGS identified and corrected the issue.

Provider Action
Proposed Resolution

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.07.2021

Closed

Part A Providers

CGS identified an error in the system edit logic related to the Local Coverage Determination (LCD) policy L33950, which may have caused some claims for annual screening mammograms to deny with reason code 54300 incorrectly.

54300

HCPCS code 77067; diagnosis code Z12.31

01.07.2021

Updates

01.07.2021 –Claim adjustments have been completed.

10.09.2020 – CGS corrected the system edit; claim adjustments are pending.

MAC Action

09.29.2020 – CGS will correct the system edit and adjust any claims denied in error.

Provider Action

09.29.2020 – No provider action is needed. This includes a redetermination request (first level of appeal) as CGS is not able to overturn the claim decision until the system edit is corrected.

Proposed Resolution

09.29.2020 – CGS will correct the system edit and adjust any claims denied in error.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

09.28.2020

Closed

IRF hospitals

Inpatient Rehabilitation Facility (IRF) claims are being returned (RTP'd) with reason code 37096 (no assessment record on file).

37096

NA

09.28.2020

Updates

09.28.2020 – iQIES resolved the issue; providers may F9/resubmit claims that RTP'd in error to process.

MAC Action

09.22.2020 – CGS is researching to determine if any claims were RTP'd in error.

Provider Action

09.22.2020 – Prior to calling the Provider Contact Center (PCC), please verify the following:

  • The patient assessment was on file in QIES prior to submitting the claim.
  • The information submitted on the claim is an exact match to the information submitted in QIES.
Proposed Resolution

09.28.2020 – iQIES identified and corrected an issue that prevented claims submitted 9.10.2020 – 9.23.2020 to match to the stored IRF-PAI assessment.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

08.27.2020

Closed

Part A Providers

We are aware of an issue with inpatient claims receiving reason code 13399 in error.

13399

NA

10.12.2020

Updates

10.12.2020 – A system correction was successfully implemented with the October release. Providers should F9/resubmit claims for processing. If reason code 13399 still applies, verify the occurrence span codes reported on the claim, make any necessary corrections and F9/resubmit the claim again.

MAC Action  
Provider Action

08.27.2020 – Additional information will be provided after the successful implementation of the October release.

Proposed Resolution

08.27.2020 – A system correction is scheduled to be implemented with the October release.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.29.2020

Closed

Part A Providers

Reason Code 37578 is causing claims submitted via Direct Data Entry (DDE) to go to the Return to Provider (RTP) file incorrectly.

37578

Physician National Provider Identifier (NPI)

8.17.2020

Updates

09.25.2020 – This issue has been resolved. A resolution to this issue was implemented on August 17, 2020.

07.09.2020 – Claims are being sent to RTP incorrectly with reason code 37578. CGS is researching the issue.

MAC Action  
Provider Action

07.09.2020 – No action necessary at this time.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.19.2020

Closed

Part A

Fax not responding

NA

NA

06.19.2020

Updates 08.26.2020 – Resolved and closed. No provider action required.
MAC Action 06.19.2020 – CGS has identified the issue and is now resolved
Provider Action 06.19.2020 – Providers are to only use the fax number on the OPD PAR form 1.615.782.4486
Proposed Resolution NA

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.05.2020

Closed

Outpatient Hospital (TOB 13X)

Some claim lines submitted with a medical visit and modifier CS may have processed with coinsurance in error.

NA

HCPCS codes assigned status indicator V or J2, or HCPCS code 99291 reported with modifier CS

08.26.2020

Updates 08.26.2020 – Resolved and closed. No provider action required.
MAC Action 06.05.2020 – CGS will identify and correct affected claims.
Provider Action 06.05.2020 – No provider action is needed.
Proposed Resolution 06.05.2020 – CGS has corrected the error.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.14.2020

Closed

Outpatient Hospital (12X TOB)

CGS became aware of some claims RTP'ing with reason code 32206 incorrectly.

32206

(12X TOB) Revenue Code 078X

08.26.2020

Updates 08.26.2020 – Resolved and closed. No provider action required.
MAC Action 05.14.2020 – CGS identified claims with 12X TOB and Rev code 078X combination RTP'ing in error.
Provider Action 05.14.2020 – If claim submitted before 5/14/2020 with 12X TOB and 078X revenue code can be PF9'ed back in for processing.
Proposed Resolution 05.14.2020 – CGS has corrected the error.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.17.2020

Closed

All Part A providers

CGS is aware of delays in answering questions that have been submitted to the CGS.ERS.CORR@cgsadmin.com mail box. Our resources have been focused on getting payments made and we are now working through the questions that have been submitted. It may take a few days to work through all the questions but you will get a response as quickly as possible.

NA

NA

06.01.2020

Updates  
MAC Action  
Provider Action  
Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.08.2020

Closed

All Part A providers

CGS is aware that certain eligible provider types may not have received the maximum eligible amount for their accelerated payment. We are identifying providers impacted by the 3-6 month max issue and determining a resolution.

NA

NA

06.01.2020

Updates

04.15.2020 – Providers who are eligible to receive a 6-month maximum amount and requested an amount greater than their 3-month maximum or requested the "maximum amount" can expect to receive an adjustment to their advance and an additional payment within the next week.

MAC Action  
Provider Action  
Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.29.2020

Closed

Outpatient Ambulance Claims

It has come to the attention of the Centers for Medicare & Medicaid Services (CMS) that the Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) edit 7275 is denying Part B ambulance claims inappropriately. This is occurring when the beneficiary is in a covered Part A SNF stay but requires a Part B covered transport for emergency services and when the transport claim is billed with Healthcare Common Procedure Coding System (HCPCS) code A0427, A0429, or A0433.

C7275 - Location SM7275

HCPCS Codes A0427, A0429, or A0433

06.01.2020

Updates

01.01.2020 – A system fix was implemented and this issue is resolved.

MAC Action

10.15.2019 – CGS will manually bypass reason code C7275 for incoming transportation claim lines containing any of the above mentioned HCPCS codes billed with or without A0425. CGS will also hold any associated Informational Unsolicited Responses (IURs) until the C7275 error code and the IUR are revised. The tentative date is January 2020.

Provider Action

NA

Proposed Resolution

10.15.2019 – CGS will reprocess claims brought to their attention that were denied in error.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.05.2020

Closed

Outpatient Hospital (13X TOB)

CGS became aware of some claims RTP'ing with reason code 7TRCR incorrectly.

7TRCR

HCPCS Codes A0427, A0429, or A0433  
Updates  
MAC Action

02.05.2020 – CGS will reprocess affected claims. Planned completion date 02.07.2020.

Provider Action

02.05.2020 – After 02.07.2020 if you feel your claim(s) were not resolved or were missed, you may PF9 the claims back in for processing.

Proposed Resolution

02.05.2020 – CGS has corrected the error.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.29.2020

Closed

Outpatient Ambulance Claims

It has come to the attention of the Centers for Medicare & Medicaid Services (CMS) that the Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) edit 7275 is denying Part B ambulance claims inappropriately. This is occurring when the beneficiary is in a covered Part A SNF stay but requires a Part B covered transport for emergency services and when the transport claim is billed with Healthcare Common Procedure Coding System (HCPCS) code A0427, A0429, or A0433.

C7275 - Location SM7275

Multiple PDPM HIPPS codes 01.06.2020
Updates

01.01.2020 – A system fix was implemented and this issue is resolved.

MAC Action

10.15.2019 – CGS will manually bypass reason code C7275 for incoming transportation claim lines containing any of the above mentioned HCPCS codes billed with or without A0425. CGS will also hold any associated Informational Unsolicited Responses (IURs) until the C7275 error code and the IUR are revised. The tentative date is January 2020.

Provider Action

NA

Proposed Resolution

10.15.2019 – CGS will reprocess claims brought to their attention that were denied in error.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.29.2020

Closed

Skilled Nursing Facility (SNF) and Swing Bed (SB) claims

The Centers for Medicare & Medicaid Services (CMS) has identified an error in the 2019 Inpatient Facility Prospective Payment System (IPF PPS) currently in production. The Fiscal Year (FY) 2019 IPF PPS Pricer applicable to dates of service on or after October 1, 2018, contains approximately 18 valid Medicare Severity Diagnosis Related Group (MS-DRGs) that are returned to provider (RTP) in error, after receiving an invalid return code '54' from the IPF PPS Pricer.

WWSNF (Location SMHSNF)

Multiple PDPM HIPPS codes 10.07.2019
Updates

11.25.2019 – A system fix was implemented and this issue is resolved.

MAC Action

10.25.2019 – CMS instructed contractors to hold claims that meet the following criteria:

  • Type of Bill (TOB) 21X and 18X subject to SNF PDPM
  • From date 10.1.19 and after
  • Multiple line items with revenue code 0022
Provider Action

NA

Proposed Resolution

10.25.2019 – CGS will release all other SNF PDPM claims previously held and reprocess any SNF PDPM claims that were processed in error prior to 10.24.19.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.29.2020

Closed

All Types of Bill

The Centers for Medicare & Medicaid Services (CMS) is aware of an issue causing the Medicare Beneficiary Identifier (MBI) on the incoming claim to link to an inactive Health Insurance Claim Number (HICN). This is impacting a limited number of claims.

38119, 30918, 30905, F5050, U5050, U5062

MBI 12.18.2019
Updates

01.01.2020 – A system fix was implemented and this issue is resolved.

10.17.2019 – The correction date for this issue has been delayed until November 18, 2019.

09.19.2019 – The claims affected by this issue are being suspended in status/location S MHMBI. A resolution to this issue has been scheduled for implementation on October 7, 2019. At that time, the claims will be released to continue processing.

MAC Action  
Provider Action

09.19.2019 – No action required.

Proposed Resolution

09.19.2019 – A resolution to this issue has been scheduled for implementation on October 7, 2019.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.25.2019

Closed

Skilled Nursing Facility (SNF) and Swing Bed (SB) claims

CMS has identified an issue related to the implementation of the Patient Driven Payment Model (PDPM).

WWSNF (Location SMHSNF)

Multiple PDPM HIPPS codes 11.25.2019
Updates

11.25.2019 – A system fix was implemented and this issue is resolved.

MAC Action

10.25.2019 – CMS instructed contractors to hold claims that meet the following criteria:

  • Type of Bill (TOB) 21X and 18X subject to SNF PDPM
  • From date 10.1.19 and after
  • Multiple line items with revenue code 0022
Provider Action

NA

Proposed Resolution

10.25.2019 – CGS will release all other SNF PDPM claims previously held and reprocess any SNF PDPM claims that were processed in error prior to 10.24.19.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.25.2019

Closed

CAH Swing Bed claims (TOB 18X with provider numbers in the range XXZ300-XXZ399)

Critical Access Hospital (CAH) Swing Bed claims are receiving a Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) edit (reason code 31864) in error.

31864

  11.25.2019
Updates

11.25.2019 – A system fix was implemented and this issue is resolved.

MAC Action

10.25.2019 – CGS will apply a workaround to process CAH Swing Bed claims correctly until a FISS fix is installed.

Provider Action

10.25.2019

  • CAH Swing Bed providers: No action is required.
  • SNF and Swing Bed providers subject to SNF PDPM: Due to the "hard" transition to PDPM on 10.1.19, a new edit (reason code 31864) was implemented that requires you to split bill. Submit a claim for September with the RUG-IV HIPPS code(s). After the September claim finalizes, submit a claim for October with the PDPM HIPPS code(s).
Proposed Resolution

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.20.2019

Closed

All Part A, Part B, home health and hospice providers

The Centers for Medicare & Medicaid Services (CMS) has identified an issue with obtaining current MSP information via the HIPAA Eligibility Transaction System (HETS). This affects MSP information available in myCGS, and the interactive voice response (IVR) system.

NA

MSP Eligibility 11.20.2019
Updates

11.20.2019 – The issue related to HETS returning incorrect MSP records is resolved.

11.11.2019 – The Common Working File (CWF) implemented system changes October 7, 2019. The CWF changes inadvertently resulted in sharing beneficiary MSP updates or new occurrences with HETS only when there is claims activity. The CWF MSP data is accurate; however, if a beneficiary's MSP information changed since October 7th and there hasn't been CWF claim activity for that beneficiary, HETS MSP data isn't current. CWF is the MSP information source for HETS, therefore, this affects the MSP information available via myCGS portal and IVR system. A resolution to this issue is scheduled for implementation the weekend of November 16th.

11.06.2019 – CGS will share updated information as it becomes available.

MAC Action

Provider Action

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.17.2019

Closed

11X – Inpatient Claims

CGS is aware of certain issues with Medicare Advantage claims.

U5233, 3719C

  • U5233: Condition codes 04, 69 and 30
  • 3719C: Condition codes 04 and 30
10.17.2019
Updates

09.19.2019 – Correction not implemented.

08.26.2019 – Correction not implemented.

07.22.2019 – Correction not implemented.

06.14.2019 – Correction has not been implemented.

05.31.2019 – Correction has not been implemented.

05.06.2019 – Correction is not implemented.

04.24.2019 – Correction is not implemented at this time.

04.03.2019 – The expected correction will not be implemented in April 2019 as planned.

02.18.2019 – No additional information. An expected resolution is scheduled for the April 2019 as mentioned in 'Proposed Resolution' below in MM10959External PDF.

01.29.2019 – No additional information at this time.

11.01.2018

  • U5233: Indirect Medical Education (IME) only claims for approved teaching hospitals billed with an Investigational Device Exemption (IDE) study or a clinical study approved under Coverage with Evidence Development (CED) for beneficiaries enrolled in a Medicare Advantage (MA) plan are rejecting in error.
  • 3719C: Inpatient information only claims for IDE studies and clinical studies approved under CED were processed with payment in error.
MAC Action

11.01.2018

  • U5233:
    • For claims received prior to October 8, 2018, CGS will identify and reprocess claims that rejected in error.
    • For claims received on and after October 8, 2018, CMS instructed MACs to apply a workaround to prevent claims from rejecting in error until a system fix is implemented.
  • 3719C: CMS instructed MACs to identify and reprocess claims with an admission/from date on or after April 1, 2015, and before March 31, 2018, that were paid in error.

10.25.2018 – CGS is researching the issues and will provide an update via this Claims Processing Issue Log (CPIL) when additional information is received.

Provider Action

08.26.2019 – Providers need to ensure they are billing their HMO Pay Code (Pay\CD) correctly.

11.01.2018

  • U5233: Providers may choose to identify claims that rejected in error and submit claim adjustments.
  • 3719C: Providers should notify CGS if they identify claims that were not reprocessed and received a payment in error.
Proposed Resolution

11.01.2018

  • U5233: A system fix is scheduled to be implemented in April 2019 per CMS MLN Matters article MM10959External PDF.
  • 3719C: A system fix was implemented in April 2018 per CMS MLN Matters article MM10238External PDF.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.15.2019

Closed

All Part A, Part B, home health and hospice providers

CGS has been notified by CWF that beneficiary eligibility dates may be missing from the CWF beneficiary files. They have received many examples and will be looking into the issue. This will affect eligibility inquiries using the myCGS portal, Interactive Voice Response (IVR) system and the CWF eligibility systems, ELGA/ELGH.

NA

Eligibility 10.15.2019
Updates

10.15.2019 – Due to processing issues at the Enrollment Database (EDB) entitlement data sent for new and/or updated beneficiaries processed at the Common Working File (CWF) between October 7, 2019 and October 9, 2019 posted with blank/ZERO entitlement dates causing some claims to reject with reason code U5200. After discovering the issue, CGS suspended some claims. The issue with the EDB has been corrected and the beneficiary entitlement dates have been restored. Please refer to the Provider Action and MAC Action section below for additional information.

10.09.2019 – Additional information will be provided when it becomes available.

MAC Action

10.15.2019 – Claims that were suspended with reason code U5200 will be released to continue processing.

10.09.2019 – No action at this time.

Provider Action

10.15.2019 – If you had claims reject with reason code U5200 as a result of this issue, please verify that the beneficiary was eligible on the date of service and the claim was rejected incorrectly, and resubmit the claim to CGS for processing.

10.09.2019 – No action at this time.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

12.04.2018

Closed

All Types of Bill

Claims may be rejecting C7010 in error when hospice overlaps the date of service on the claim.

C7010

  05.31.2019
Updates

05.31.2019 – This issue has been resolved.

05.06.2019 – No additional information at this time.

04.24.2019 – No additional information at this time.

04.03.2019 – No additional information at this time.

03.18.2019 – No additional information at this time.

02.18.2019 – No additional information at this time.

01.29.2019 – No additional information at this time.

12.04.2018 – This is occurring when the date of service is equal to a hospice election date or revocation date. Services which occur on the same day a beneficiary elects hospice or after the revocation of hospice benefits are separately payable by Medicare.

MAC Action

12.04.2018 – CGS is researching and will update the CPIL once the correction has been determined.

Provider Action

NA

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.12.2019

Closed

11X – Inpatient

FISS is not retaining value codes 09 and/or 11 when value codes 83, 08 and/or 10 are removed by the system on inpatient claims (TOB 11X).

Location SMIHIS

   
Updates

05.06.2019 – All claims have been released and are processing appropriately.

04.24.2019 – Update has been implemented. CGS is releasing claims to ensure correction is working as expected.

MAC Action

04.04.2019 – The correction to the issue has been delayed until April 22, 2019.

04.03.2019 – Correction is scheduled to be implemented on April 4, 2019 and suspended claims will be released.

03.12.2019 – Claims are suspending with utilization reason codes when coinsurance days are present without coinsurance value code and amount. Estimated correction for this issue is April 4, 2019.

Provider Action  
Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.10.2019

Closed

Part A

The Medicare Part B payment allowances for HCPCS code Q2038 (flu vaccine) is not yet available.

37580 and 36602

HCPCS code Q2038 and CPT code 90661 (flu vaccine)

 
Updates

05.06.2019 – Products described by these codes have not been available since 2016; therefore, the Centers for Medicare & Medicaid Services (CMS) do not have a payment amounts for these codes. Claims with these codes will be sent to the Return to Provider (RTP) file with reason code 79079 for providers to correct the claim with a valid code.

04.24.2019 – Corrections have still not been issued.

04.03.2019 – Corrections have still not been issued.

03.18.2019 – No update at this time. Refer to MM10914.

02.18.2019 – No update at this time. Refer to MM10914 as referenced below.

01.29.2019 – The CPT code 90661 has been added to this issue.

01.10.2019 – Claims with dates of service on or after August 1, 2018, through July 31, 2019, submitted with HCPCS code Q2038 (flu vaccine) are being suspended in status/location S MFLU1. Refer to MM10914External PDF for additional information.

MAC Action

01.10.2019 – Claims are being suspended in status/location S MFLU1 until the payment allowance is available.

Provider Action 01.10.2019 – No action is necessary by providers.
Proposed Resolution 01.10.2019 – Once the payment allowance is available, claims will be released to continue processing.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.12.2019

Closed

03.12.2019 – CMS is aware of an issue with outpatient services that ties to MM11016External PDF – January 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files. A file data error has been discovered where the rates for two (2) Drug Codes were incorrectly priced in the October, 2018, restated file and five (5) Drug Codes were incorrectly priced in the January, 2019, file. This error caused the affected claims to be paid incorrectly. CMS implemented ASP drug file corrections retroactive to October 1, 2018, for the October restated file and to January 1, 2019, for the January file.

Issue with five drugs priced incorrectly in previous Average Sales Price (ASP) updates.

NA

The affected codes are below:

For the October 2018 restated file:

  • Dates of service on or after October 1, 2018; and
  • HCPCS codes Q4172 or Q9950.

For the January 2019 file:

  • Dates of service on or after January 1, 2019
  • HCPCS Q4195, Q4196, Q5105, Q5106 or Q9950.
 
Updates 05.06.2019 – CGS adjusted affected claims. If others are located that were not included, bring to the attention of CGS.
MAC Action

04.03.2019 – CGS will adjust the affected claims by July 1, 2019.

03.12.2019 – For any drug or biological not listed in the ASP or NOC drug pricing files, your MACs will determine the payment allowance limits in accordance with the policy described in the Medicare Claims Processing Manual, Chapter 17, Section 20.1.3External PDF.

Provider Action 03.12.2019 – MACs will not search and adjust claims that have already been processed unless you bring such claims to their attention.
Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.04.2019

Closed

Critical Access Hospital (CAH) 85X type of bill

Claims will be suspended in location SM0291 until the enhancement is implemented.

NA

HCPCS codes G2001 through G2009, G2013, G2014, or G2015

 
Updates  
MAC Action

04.24.2019 – Claims were released.

04.04.2019 – CAH claims will be suspended for date of service January 1, 2019 and greater in location SM0291 until testing has been completed. CGS will release the claims on the 15th day.

Provider Action  
Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.23.2018

Closed

Claims submitted with a patient's HIC are not populating to the SPR although the information is showing on the 835 file. This issue does not affect claims billed with a patient's Medicare Beneficiary Identifier (MBI) number. The System Maintainer has confirmed this is global issue across all MACs.

Claims submitted with a patient's HIC rather than the MBI are not populating to the SPR although the information is showing on the 835 file.

NA

NA

 
Updates

04.24.2019 – Correction has been implemented.

04.03.2019 – The correction to the issue will be implemented into production on April 22, 2019.

MAC Action

03.12.2019 – The fix for this issue is scheduled to be implemented into production on April 22, 2019.

Provider Action

03.12.2019 – Providers may bypass this issue by submitting claims with the MBI. Only claims submitted with the HIC number are not populating the patient's name on the SPR.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.23.2018

Closed

Part A Claims

Providers may be receiving denials stating that no MolDX Z-ID was listed on the claim or the MolDX Z-ID and HCPCS associated is a mismatch.

5D605

All MolDX codes

04.24.2019

Updates

04.24.2019 – Incorrect denials are no longer occurring.

04.03.2019 – A line item was added to the claim line to add the Z-identifier with the April release.

02.18.2019 – Providers that have submitted claims with correct identifiers and should have been paid will be adjusted.

01.29.2019 – Some claims that were denied in error will be adjusted.

08.02.2018 – No update at this time.

07.11.2018 – No update at this time.

06.27.2018 – No update at this time.

06.08.2018 – No update at this time.

05.22.2018 – No updates at this time.

04.23.2018 – No update at this time.

MAC Action

04.09.2018 – CGS has determined that some providers have submitted requests through the DEX Diagnostics ExchangeExternal Website, which will provide a Z identifier that is related to the test submitted along with the documentation submitted to support how the test is performed. Providers are billing claims with the MolDX Z-ID before the documentation is reviewed by the MolDX team and prior to letter being sent to the provider giving the outcome of their registration. Research has also shown that the Z-ID being submitted with a HCPCS code is not the one that is associated with Z-ID on file.

Provider Action

04.09.2018 – Providers who have received denial 5D605 should verify against the letter sent to you from the MolDX team that you are using the correct code associated with MolDX Z-ID on the claim. Providers who have recently registered for a MolDX Z-ID for a test and have not received a letter from the MolDX team letting them know the outcome of the registration may submit claims; however, the line for that test will be denied until the MolDX team has finished the review or claims will be held until the registration process has been completed. Providers who have registered a test through DEX exchange and received a Z-identifier, but have not uploaded the supporting documentation for the MolDX team to receive and review should submit the needed documentation to complete the process.

Reference: CGS-MolDX Test Registration (CM00003)

Claims that have denied with reason code 5D605 should be submitted as redetermination requests.

Proposed Resolution

04.01.2019 – Providers may obtain eligibility information by accessing myCGS or the Interactive Voice Response (IVR).

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.02.2019

Closed

Part A Claims

The Common Working File (CWF) eligibility inquiry screens (ELGA/HIQA) are not allowing providers to access eligibility information.

NA

ELGA/HIQA

04.02.2019

Updates  
MAC Action  
Provider Action

04.02.2019 – The issue was corrected on April 2, 2019 and providers are able to access the affected screens.

04.01.2019 – CGS is currently researching this issue and FISS has been notified. This issue affects all contractors.

Proposed Resolution

04.01.2019 – Providers may obtain eligibility information by accessing myCGS or the Interactive Voice Response (IVR).

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.18.2019

Closed

Claims that have HCPCS codes 76706, 76977, 77078, 77080, and 77081 that contain a modifier of FX or FY that were processed prior to implementation of the release of the revised 2019 OPPS Pricer.

A small number of claims were processed incorrectly.

NA

NA

03.18.2019

Updates

03.18.2019 – Affected claims have been reprocessed.

MAC Action

03.12.2019 – MACs to reprocess claims.

Provider Action  
Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.22.2019

Closed

RailRoad (RRB) Medicare Beneficiaries

Railroad beneficiary claims rejecting with reason code U5245.

U5245

NA

02.22.2019

Updates

02.22.2019 – This issue is resolved.

02.18.2019 – CGS is waiting on direction from the CWF Maintainer.

01.29.2019 – No update at this time.

MAC Action

12.26.2018 – CGS is researching to determine if Railroad beneficiary claims are rejecting in error for Coronary Artery Bypass Graft surgery, or in a Centers of Excellence Demonstration.

Provider Action

02.22.2019 – Providers may adjust any claims that rejected incorrectly. Move non-covered charges back to covered.

12.26.2018 – Watch for updates via the CPIL.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

12.11.2018

Closed

Part A

Some claims adjusted by CGS are not making payment. These are claims that initially received Reason Code 30909 in error.

30909/37205

NA

12.10.2018

Updates

12.11.2018 – This issue has been resolved.

12.04.2018 – Affected claims will be suspended in status/location S M0909. Updated information will be provided as it becomes available.

MAC Action

12.11.2018 – The suspended claims in status/location S M0909 have been released to continue processing.

Provider Action

12.11.2018 – No provider action at this time; however, if you have a claim in the return to provider (RTP) file with this reason code, you may F9 the claim to release for continued processing. If there are rejected claims without payment, you may adjust the claim.

12.04.2018 – No provider action is required at this time.

Proposed Resolution 12.04.2018 – Until this issue is resolved, affected claims will be suspended in status/location S M0909.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.11.2018

Closed

ESRD - 72X Type of Bill

ESRD claims are claim level rejecting with Reason Code 36342 instead of line item rejecting. CGS is aware of the issue and affected claims will be adjusted appropriately, or providers may adjust rejected claims if needed.

36342

October Release

12.31.2018
Updates

01.29.2019 – This issue has been resolved.

12.18.2018 – ESRD adjustments are being initiated as of the week of December 17th. If you do not see affected claims adjusted by December 31, you should initiate adjustments on claims rejected in error in DDE.

10.18.2018 – CGS has researched the ESRD claims level rejections and identified that claims rejected (status location RB9997) as originally instructed by CMS. Due to provider impact, CGS has been granted the ability to update the process to change reason code 36342 back to line level reject. ESRD claims are line level rejecting as of October 11, 2018.

MAC Action

10.18.2018 – CGS will adjust the impacted ESRD claims. The process will take 60 days to initiate the adjustments.

10.12.2018 – Reason Code 36342 has been set to reject at the line item correctly. CGS will process adjustments to correct the issue.

Provider Action

12.18.2018 – See "Updates".

10.18.2018 – Providers may adjust the rejected claims via Direct Data Entry (DDE) if needed prior to the 60 day timeframe. Instructions for adjusting rejected claims can be located at the following link: Claim Status and Corrections

10.12.2018 – Review CPIL and remittance advices.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.05.2018

Closed

Outpatient Facilities

Claims with HCPCS Code Q5110 held until January 2019 quarterly I/OCE is implemented.

W7006

Location SM0569 - HCPCS Code Q5110

12.31.2018
Updates 01.29.2019 – This issue has been resolved with the release.
MAC Action

10.05.2018 – CMS has identified a problem with the Integrated Outpatient Code Editor (IOCE) assigning reason code W7006 on claims submitted with Healthcare Common Procedure Coding System (HCPCS) Code Q5110. CGS will correct any claims previously RTPd to the provider with HCPCS Code Q5110 and reason code W7006.

Provider Action

10.05.2018 – No provider action is required.

Proposed Resolution

10.05.2018 – Once the January 2019 I/OCE is implemented, the claims will be released.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.17.2018

Closed

All Types of Bills

Certain claims are in RTP status with reason code 1A005 indicating that the middle initial of the beneficiary's name is incorrect.

1A005

NA

10.22.2018
Updates

10.22.18 – The issue has been resolved and should not be occurring after this date of service. Providers will need to resubmit claims that initially RTPd with this reason code.

MAC Action

NA

Provider Action

10.17.2018 – Providers will need to ensure the patient's middle initial is either blank, or an alpha character A – Z. Claims will need to be resubmitted as information has been removed from the claim.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.10.2018

Closed

Part B and Part A

Electronic Claims rejecting on the Front End on the 277CA report for diagnosis codes effective 10/1/2018

 

ICD 10 codes effective 10/1/2018

10.10.2018
Updates
MAC Action

10.10.2018 – Reloading the CCEM ICD 10 table correctly

Provider Action

10.10.2018 – Must resubmit the files once the issue is resolved.

Proposed Resolution

10.10.2018 – We are in the process of correcting this issue. The CCEMs will not be producing 277CAs while we are correcting this issue. It will approximately take 2 hours to complete, ETA 1:30 pm EST.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.05.2018

Closed

IPPS and LTCH – 11X Type of Bill

FY 2019 IPPS and LTCH PPS Claims Hold

WW551

Location SM0551

10.22.2018
Updates
MAC Action

10.22.2018 – Held claims released.

10.05.2018 – Due to revised rates and factors in the FY 2019 Inpatient and Long-Term Care Hospital (LTCH) Prospective Payment Systems (PPS(s)) final rule correction notice, CGS will hold claims with discharge dates on or after October 1 through October 22, 2018.

Provider Action

10.05.2018 – No provider action is required.

Proposed Resolution

10.05.2018 – Claims will be released beginning October 23, 2018.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

09.24.2018

Closed

Some institutional adjustments

Certain adjustments are RTPing in error with Reason Code EA002.

EA002

NA

10.01.2018
Updates
MAC Action

09.24.2018 – FISS has determined that this is an issue and a correction will be implemented in the October 1, 2018 release.

Provider Action

09.24.2018 – Providers may F9 the adjustment after the release is implemented to allow them to process. If the adjustment has been suppressed and has an 'X' tape to tape flag, the claim will need to be resubmitted.

Proposed Resolution

09.24.2018 – FISS will correct editing in the October release, which will be implemented October 1, 2018.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

08.22.2018

Closed

IPF Facilities

A subset of Inpatient Psychiatric Facility (IPF) claims are cycling with reason code C7563.

C7563

Location SM7563

10.01.2018
Updates
MAC Action

08.22.2018 – This subset of claims is being suspended in status location SM7563 until the FISS correction is implemented on September 3, 2018, and on October 1, 2018, respectively. Affected claims will be released to process after the corrections are implemented.

Provider Action

08.22.2018 – No action required.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

08.16.2018

Closed

All CGS J15 Providers

Some providers are not able to view any Greenmail letters in the myCGS portal. Links for their letters display, but providers are unable to view.

NA

NA

08.17.2018
Updates

08.17.2018 – Providers are now able to open letters received via myCGS Greenmail. We apologize for the inconvenience.

08.16.2018 – This issue is being researched.

MAC Action  
Provider Action

08.16.2018 – None at this time.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.25.2018

Closed

Critical Access Hospitals (CAH)

85X bill types suspended and workaround performed by CGS

W7020, W7040, W7106, W7107, and W7108

NA

10.01.2018
Updates
MAC Action

10.04.2018 – Claims released.

07.25.2018 – Effective immediately, CGS will suspend claims with reason codes mentioned to location SM0452 and perform a workaround to process.

Provider Action

07.25.2018 – CAH providers should adjust claims that rejected for reason codes W7020 and W7040 in error.

Proposed Resolution

07.25.2018 – Additional instructions regarding reprocessing of claims with Reason Codes W7106, W7107, and W7108 will be communicated at a later date for the October 2018 release.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.09.2018

Closed

Part A Providers

Providers are unable to access eligibility information via the FISS Direct Data Entry (DDE) screen Option 10, Beneficiary/CWF.

NA

NA

07.30.2018
Updates

07.30.2018 – This issue was resolved earlier than scheduled. Providers should now be able to access CWF eligibility information using FISS Inquiry Option 10, Beneficiary/CWF.

MAC Action

07.09.2018 – A resolution to this issue is tentatively scheduled for August 6, 2018.

Provider Action

07.30.2018 – No action required.

07.09.2018 – Providers may use the IVR, ELGA, or myCGS to access Medicare eligibility information.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.02.2018

Closed

All myCGS Users

myCGS portal Greenmail letters have not been delivered

NA

NA

08.01.2018
Updates

08.01.2018 – Notified that letters were sent out with the original dateon July 2, 2018 and all follow up actions have been completed. In addition, processes put in place to ensure this does not occur again.

07.03.2018 – On Monday, July 2nd, it was discovered that providers who are opted in for myCGS Greenmail did not receive letters in the portal beginning June 19th through June 29th. Impacted letters were sent via myCGS on July 2nd. Updated letters are also being generated to account for the delay and extend timeliness requirements. We will provide an update once these letters are available. We apologize for the inconvenience. Please note this only impacts providers who do not receive hard copy letters and are opted in to myCGS Greenmail.

MAC Action 07.02.2018 – CGS is researching the issue.
Provider Action

07.03.2018 – Please Note: This message only impacts providers who do not receive hard copy letters and are opted in to myCGS Greenmail.

07.02.2018 – No action at this time.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.11.2018

Closed

Outpatient 13X type of bill

It has been brought to CGS' attention by CMS that Positron Emission Tomography (PET) claims containing certain radiopharmaceutical Healthcare Common Procedure Coding System (HCPCS) codes are returning to provider (RTP'ing) in error as of January 1, 2018, date of service (DOS).

Reason Code 32440
HCPCS Codes:
A9515, A9586, A9587, and A9588

NA

10.01.2018
Updates

10.04.2018 – Claims released.

07.11.2018 – Refer to Provider Action below.

06.27.2018 – No update at this time.

MAC Action

06.11.2018 – There is a permanent fix in Change Request (CR) 10622External PDF to be implemented in the October 2018 release.

Provider Action

06.11.2018 – If providers are aware of claims that RTP'd in error with reason code 32440, they may F9 the claim(s) or resubmit.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.04.2018

Closed

Inpatient Prospective Payment System (IPPS) Providers

The Fiscal Intermediary Shared System (FISS) has determined that Inpatient claims with patient status codes 02 and 82 are being overpaid (overpayment of the Diagnosis Related Group (DRG).

NA

NA

07.23.2018
Updates

06.27.2018 – No update at this time.

06.08.2018 – A correction is tentatively scheduled for July 23, 2018.

MAC Action  
Provider Action

N/A

Proposed Resolution 06.04.2018 – Once FISS has determined a correction it will be implemented and CGS will initiate adjustments to collect against overpayments.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.22.2018

Closed

Part A Providers

Claims submitted for processing with a Medicare Beneficiary Identifier (MBI) that were returned for valid reasons currently cannot be corrected through the Fiscal Intermediary Shared System (FISS) Direct Data Entry (DDE) system. The issue will be resolved no later than Tuesday, July 3, 2018.

NA

NA

07.02.2018
Updates

07.30.2018 – A fix to this issue was implemented on July 2, 2018.

07.11.2018 – Refer to Provider Action below.

06.27.2018 – No update at this time.

06.08.2018 – No update at this time.

MAC Action  
Provider Action

07.30.2018 – Providers should be able to correct claims out of the RTP file that were submitted with an MBI.

05.22.2018 – To avoid delays in payment, submit a new claim to CGS if an MBI claim was returned to you.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.22.2018

Closed

Part A Providers

Claims submitted for processing with a Medicare Beneficiary Identifier (MBI) that were returned for valid reasons currently cannot be corrected through the Fiscal Intermediary Shared System (FISS) Direct Data Entry (DDE) system. The issue will be resolved no later than Tuesday, July 3, 2018.

NA

NA

07.02.2018
Updates

07.30.2018 – A fix to this issue was implemented on July 2, 2018.

07.11.2018 – Refer to Provider Action below.

06.27.2018 – No update at this time.

06.08.2018 – No update at this time.

MAC Action  
Provider Action

07.30.2018 – Providers should be able to correct claims out of the RTP file that were submitted with an MBI.

05.22.2018 – To avoid delays in payment, submit a new claim to CGS if an MBI claim was returned to you.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.22.2018

Closed

Part A Providers

The Fiscal Intermediary Standard System (FISS) has identified an issue with some Medicare Secondary Payment (MSP) claims.

U6803, U6816, U6817, U6818, U6819, U681D, U681E, U681L, 39074

Suspend in Location SM0628

09.17.2018
Updates

09.17.2018 – Issue is resolved. Claims suspended in SM0628 have been released to process.

08.22.2018 – CGS has been notified that MSP claims with reason codes U681D, U681E, and U681L will be held in status location SM0628 until the October 2018 system release is implemented on October 1st.

07.31.2018 – MSP claims currently being held with reason codes U6803, U6816, U6817, U6818, U6819, U681E, U681L, or 39074 will be released to continue processing as usual.
MSP claims being held with reason code U681D will continue to be held. We anticipate a fix to this issue to be implemented on August 20, 2018.

06.22.2018 – A new correction has been implemented and will go into production on July 23, 2018.

06.08.2018 – No further update at this time.

05.23.2018 – Reason code 39074 has been added to the list of codes to suspend.

MAC Action

05.22.2018 – MSP claims hitting an identified reason code (Reason Codes) will be suspended and not Returned to Provider (RTP). The correction for this issue will be installed into production on July 2, 2018, and suspended claims will be released.

Provider Action  
Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.17.2018

Closed

SNF

Claims are being submitted with the new Medicare Beneficiary Identifier (MBI) and the Fiscal Intermediary Standard System (FISS) is attaching an invalid Health Insurance Claim Number (HICN) to the claim, causing the claim to go to the Return to Provider (RTP) file for various reasons.

38119

MBI

07.02.2018
Updates

07.02.2018 – The release was installed and affected claims have been released.

06.27.2018 – No further update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – No update at this time.

05.17.2018 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions to suspend skilled nursing facility (SNF) claims submitted with an MBI that receive reason codes 38119 until an update is installed. The update is currently scheduled for July 2, 2018. The affected claims will be suspended in status/location S MPMBI.

MAC Action

05.17.2018 – After the update, which is currently scheduled for July 2, 2018, is implemented, CGS will release the claims to continue processing.

Provider Action

05.17.2018 – No action required.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.14.2018

Closed

Part A Outpatient 13X Type of Bill

Because of a known Fiscal Intermediary Standard System (FISS) issue, outpatient claims were recycling in the Common Working File (CWF) inappropriately. This issue was/is occurring because the allowed amounts associated with the Average Sales Price (ASP) drugs are not able to be included in with the EXP TO DED field.

E461J

Claims will be suspended in location SME461 until the system is corrected.

10.01.2018
Updates

10.04.2018 – Claims released.

06.27.2018 – No update at this time.

05.22.2018 – No recurring updates will be provided on this since the implementation is October 1, 2018 and claims will be released at that time.

MAC Action

05.14.2018 – The correction for this issue will not be implemented until the October FISS release, which will be October 1, 2018. CGS will then release all affected claims to process.

Provider Action

NA

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.10.2018

Closed

Part A Providers

Claims are RTPing stating that "The Health Insurance Claim (HIC) number is not found in the Common Working File (CWF) Crosswalk."

U5061

NA

06.27.2018

Updates

06.27.2018 – It has been determined that this is not an issue.

06.11.2018 – No update at this time.

05.22.2018 – No update at this time.

MAC Action

05.10.2018 – CGS is researching to determine if there is an issue.

Provider Action

05.10.2018 – Monitor J15 Part A Claims Processing Issues Log for updates.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.09.2018

Closed

Part A Claims

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).

NA

HICN/MBI

06.04.2018

Updates

06.06.2018 – A resolution to this issue was implemented on June 4, 2018.

05.22.2018 – No update at this time.

05.09.2018 – If you use the MBI returned through this display error on claims, the beneficiary will receive a Medicare Summary Notice with the MBI on it, possibly before they receive their new Medicare card containing their MBI. This issue will be resolved no later than May 29, 2018.
For More Information

MAC Action

No action at this time.

Provider Action

05.09.2018 – To avoid confusion, please do not use a beneficiary's MBI until one of these occur:

  • They present their new Medicare card (which will contain their MBI)
  • The MBI is available through your Medicare Administrative Contractor's secure portal
  • Their MBI is shared through the remittance advice starting in October 2018
Proposed Resolution

05.07.2018 – This issue will be resolved no later than May 29, 2018.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.07.2018

Closed

Outpatient Hospital (13X type of bill)

The Office of Inspector General (OIG) determined that Medicare payments were made inappropriately - Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities.

NA

NA

06.30.2018
Updates

06.30.2018 – Adjustments have been completed.

06.27.2018 – No update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – No update at this time.

MAC Action

05.07.2018 – CMS has instructed Medicare Administrative Contractors (MACs) to adjust claims that were inappropriately paid within dates January 1, 2013 through March 31, 2017. Claims can be identified as XXK type of bill and the 'Remarks' page of the claim(s) will indicate "A-09-16-02026". Adjustments are to be completed by June 20, 2018.

Provider Action

05.07.2018 – Providers must refund all improperly collected deductible and/or coinsurance amounts to the beneficiaries. Reference material in article linked above in Description of Issue, i.e., SE17033.

Proposed Resolution

NA

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.01.2018

Closed

Inpatient Prospective Payment System Claims (IPPS)

With the implementation of Change Request 10145, certain IPPS claims with Patient Status Code 07 are not processing correctly.

NA

Patient Status Code 07

06.30.2018
Updates

06.30.2018 – Mass adjustments have been completed.

06.27.2018 – No update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – No update at this time.

MAC Action

05.01.2018 – CGS will mass adjust impacted claims by June 22, 2018. Impacted claims will have receipt date of on or after 01.02.2018 through 04.23.2018, which is the date the correction was implemented.

Provider Action

NA

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.25.2018

Closed

Skilled Nursing Facility (SNF) Providers

During the installation of the January 2018 release, the CWF Host did not synchronize a CWF table necessary to include updates for Change Request 10262, 2018 Annual Update of HCPCS Codes for SNF CB UpdateExternal PDF. As a result, a number of SNF claims were rejected in error.

C7252

HCPCS codes A9606, C9741, J9022, J9023, J9034, J9203, J9285 or J9301.

06.30.2018
Updates

06.30.2018 – Mass adjustments have been completed.

06.27.2018 – No update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – Adjustments for claims rejected in error will be completed by June 25, 2018.

MAC Action

04.25.2018 – CGS will mass adjust impacted claims within 60 calendar days.

Provider Action

NA

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.19.2018

Closed

Providers who submit claims for Molecular Diagnostic (MolDX) testing

Upon retiring the MolDX BioFire Gastrointestinal (GI) Panel, there is question as to whether the test, billed with CPT codes 87507 or 87999, is, in fact, a part of MolDX.

NA

MolDX CPT codes 87507 and 87999

06.22.2018

Updates

06.22.2018 – Adjustments for claims with this issue have been completed.

06.08.2018 – No update at this time.

05.22.2018 – Part A affected claims have been identified, but there is no definitive date as to when the claim will be adjusted.

MAC Action

CGS is currently analyzing data back to 01.01.2017 to determine validity and our next steps.

Provider Action

No action required for providers.

Proposed Resolution

TBD

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.13.2018

Closed

RHC/FQHC Providers

It has been brought to the attention of CMS that the claims processing system is reading the incorrect rate for care management services.

NA

HCPCS Codes G0511 and G0512

05.22.2018

Updates

05.25.2018 – There were no RHC/FQHC claims identified to adjust.

MAC Action

04.13.2018 – CGS will update the codes and adjust affected claims from January 1, 2018 to present to correct the rate within approximately 60 business days.

Provider Action

NA

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.30.2018

Closed

Outpatient Providers

An error was identified in the April 1, 2018 Medicare Facility/Outpatient Hospital Services MUE edit file. The OPH MUE values for CPT code 88185 (flow oximetry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (list separately in addition to code for first marker) and CPT code 80055 (Obstetric panel) were inadvertently added as a value of "0" effective April 1, 2018.

NA

CPT codes 80055 and 88185

05.15.2018

Updates

05.22.2018 – No update at this time.

04.23.2018 – No update at this time.

MAC Action

03.30.2018 – Since the Fiscal Intermediary Shared System (FISS) will not be able to make the NCCI OPH MUE Replacement file available in production until May 7, 2018, CGS will suspend all claims that contain the two CPT codes, for dates of service on or after April 1, 2018.

Provider Action

NA

Proposed Resolution

03.30.2018 – Once the NCCI OPH MUE Replacement file is implemented into production, CGS will release all claims.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.29.2018

Closed

All Part A Providers

The Fiscal Intermediary Standard System (FISS) rejected Non-Group Health Plan (GHP) (No-Fault, Worker's Comp, and Liability) claims processed on or after October 3, 2016, incorrectly.

34133, 34134, 34137, 34138, 34139, 34140, 34141, 34142, 34143, 34144, 34145, 34146, 34147, 34148, 34149, 34152, 34153, 34154, 34299, 34300, 34304, 34379, 34381, 34383, 34507, 34508, 34512, 34544, 34545 or 34549

No-Fault, Worker's Comp, and Liability

10.01.2018

Updates

10.30.2018 – The issue was resolved with the October quarterly release.

08.20.2018 – No update at this time.

08.02.2018 – No update at this time.

06.27.2018 – No update at this time.

06.08.2018 – No update at this time.

05.22.2018 – No update at this time.

04.23.2018 – CGS will not adjust the incorrectly rejected claims until further direction is received from the Centers for Medicare and Medicaid Services (CMS).

03.30.2018 – FISS will install a fix on April 23, 2018 and claims rejected incorrectly shall be adjusted.

MAC Action

04.23.2018 – Adjustments have been put on hold until further direction.

03.30.2018 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions for CGS to mass adjust claims rejected with the above listed reason codes once the fix has been installed.

Provider Action

10.30.2018 – Providers may adjust any claims that were rejected incorrectly with any of the 34XXX codes.

Proposed Resolution

03.30.2018 – FISS will install a fix on April 23, 2018.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.02.2018

Closed

TOB 11X, 12X, 13X, 71X, 72X, 77X, AND 85X

CGS is aware that some non-invasive vascular studies (93965, 93970, and 93971) were denying in error because the diagnosis in the PRV field was not being detected.

53988

NA

05.15.2018

Updates

05.15.2018 – Adjustments have been completed.

05.02.2018 – CGS is still in the process of adjusting identified claims. The date has been extended to May 15, 2018.

04.23.2018 – No update at this time.

04.09.2018 – CGS is in the process of adjusting identified claims that were denied in error. Adjustments will be complete by the end of April 2018.

03.28.2018 – The issue with the edit has been corrected as of March 5, 2018.

MAC Action

03.02.2018 – CGS will identify and adjust claims affected by this issue.

Provider Action

03.28.2018 – Monitor CPIL for timeframe of adjustments.

03.02.2018 – Watch for adjusted claims on remittance advices.

Proposed Resolution

03.02.2018 – Once the correction is made, affected claims will be adjusted.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.20.2018

Closed

All Part A Providers

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

NA

Appeal Redeterminations

04.25.2018

Updates

04.25.2018 – The CMS MAS contractor has identified all the effectuations involved in this issue. A permanent correction is scheduled for implementation in May. Until then, a report will be run so that all effectuations are identified and are processed as appropriate.

04.16.2018 – No update at this time.

03.20.2018 – The correction is expected to be implemented in May 2018. CGI, the Medicare Appeals Contractor (MAS) is attempting to obtain a report to identify the appeals.

03.07.2018 – No update at this time. CGS continues to work with the CMS MAS contractor.

MAC Action

02.20.2018 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS) MAS contractor.

Provider Action

02.20.2018 – Update: CGS is unable to identify the claims affected by this issue. Therefore, if you have received a partially or fully favorable appeal decision outside of 60 days, and have not yet received payment, please contact the CGS Provider Contact Center at 1. 866.590.6703, Option 1.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.13.2018

Closed

Inpatient Claims – 11X Type of Bill

There is a potential issue with inpatient claims being RTP'd with reason code 37001 because of an issue in the provider file.

37001

NA

04.13.2018

Updates

04.13.2018 – Release from the Fiscal Intermediary Standard System (FISS) was put into production on April 2, 2018 and all claims have been F9'd back into the system. If you locate claims that have not been put back into the system, you may F9 them.

03.28.2018 – Correction will go into production on April 2, 2018. Claims in RTP status will be brought back into the system to process.

MAC Action

03.13.2018 – CGS is researching the issue and the Fiscal Intermediary Standard System (FISS) is aware.

Provider Action

03.28.2018 – Monitor claims to ensure processing.

03.13.2018 – Affected providers should monitor this CPIL for updates.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.29.2018

Closed

Outpatient

CGS Is aware that there is an issue with Rural Health Clinic (RHC) claims with Qualifying Visits that are being Rated in error.

32402

NA

04.10.2018

Updates

04.10.2018 – Claims with RHC Qualifying Visits that were RTP'd in error have been F9 and released to process.

MAC Action

03.29.2018 – CGS will identify and release claims (F9) affected by this issue.

Provider Action

04.10.2018 – If providers believe they have remaining claims that were not released to process, they may F9 them and they should process correctly. Refer to Rural Health Clinic Qualifying Visit ListExternal PDF and MM9269External PDF for billing instructions.

Proposed Resolution

03.29.2018 – CGS to correct issue and release claims.

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.20.2018

Closed

Outpatient Therapy

Per CR 10531, dated March 20, 2018External PDF, CMS has advised contractors to reprocess claims with the KX modifier that did not pay as they should have. Adjustments cannot be initiated until after April 2, 2018. Due to other reprocessing instructions listed in the CR, CMS has given a six month timeframe for the mass adjustments to be processed.

N/A

Therapy Services

04.16.2018
Updates

04.16.2018 – Adjustments for this issue have been completed. If you have claims that you feel may have been missed, bring to the attention of CGS by contacting the PCC. Otherwise, submit as a redetermination.

MAC Action

04.16.2018 – Affected claims have been adjusted.

03.23.2018 – Preparing to reprocess claims.

Provider Action

04.16.2018 – Monitor remittance advices for adjusted claims.

03.23.2018 – No provider action at this time. Watch CPIL for updates for completion of reprocessing.

Proposed Resolution

03.23.2018 – CGS to adjust affected claims as directed.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.02.2018

Closed

SNF Providers

CGS is aware that some Influenza and Pneumococcal Codes are not paying even though the administration code is.

NA

NA

04.16.2018

Updates

04.16.2018 – Additional codes (vaccine and administration) were identified and claims have been adjusted.

03.23.2018 – There were additional claims that needed to be adjusted and are in process.

03.02.2018 – Adjustments still in process

02.16.2018 – CGS has determined a correction and will be mass adjusting all 22X and 23X types of bills that may have been affected.

MAC Action

02.16.2018 – CGS will mass adjust claims affected by this issue. This may take up to three weeks for mass adjustments to be processed.

Provider Action

02.16.2018 – Providers may adjust the claims themselves instead of waiting on mass adjustments.

Proposed Resolution  

Back to the top of the page Top

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.29.2018

Closed

Outpatient providers

The FISS Maintainer has verified that some Part A claims are receiving reason code 32404 in error.

32404

NA

03.05.2018

Updates

02.12.2018 – A correction is expected to be placed into production on 03.05.18, and claims released from suspended location.

MAC Action

01.29.2018 – Affected claims are currently suspending in location SM3240 until corrective instructions are received by CMS.

Provider Action

01.29.2018 – No action is required at this time.

Proposed Resolution

02.12.2018 – Claims suspended in location SM3240 will be released from suspense.

01.29.2018 – Once correction is received, affected claims that were suspended will be released for processing.

Back to the top of the page Top

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved