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.


Print | Bookmark | Email | Font Size: + |

Part B Resolved Claims Issues

Date Closed Description of Issue
11.20.2023
– Closed
Claims for CPT codes 90480, 91318, 91319, 91320, 91320, 91321, and 91322 were denied in error.
10.31.2023
– Closed
Some claims received on October 11th and 12th were priced at $26.14 for services in error. This only impacted services that pay under the Physicians Fee Schedule and were performed in a facility setting.
07.14.2023
– Closed
Claims for ambulance mileage code A0425 processed in May and June of 2023 were paid incorrectly at the rural rate. This caused some overpayments.
06.29.2023
– Closed
Claims for P9603 & P9604 were denied in error.
06.29.2023
– Closed
Claims with JZ modifier have been rejected in error.
06.22.2023
– Closed
There were a few drug codes that were priced incorrectly for dates of service 04/01/2023 and after.
09.12.2022
– Closed
Claims submitted with an Investigational Device Exemption (IDE) number. Claims processed from September 1st through September 12th may have denied in error when the IDE number was submitted on the claim.
08.16.2022
– Closed
CMS identified a national system issue, which may have inadvertently adjusted previously processed Part B claims with dates of service (DOS) on or after January 1, 2021. These adjustments processed on July 29 through August 2, 2022
07.22.2022 Attention RSNAT myCGS Portal Users: Although PTAN information is not required in the section "Certifying Physician Information" on the prior authorization form to submit your RSNAT prior authorization request, we have found that to process requests through the portal you will need the PTAN information. This is temporary and CGS is aware of the issue. It will be resolved by 7/29. If you do not know the PTAN information you still can submit your requests via fax or mail.
05.06.2022
– Closed
HCPCS code J2326 denied when billed with place of service code 19 (Off Campus-Outpatient Hospital)
05.03.2022
– Closed
Some COVID codes were set up incorrectly. Claims were denied in error for referring physician, or the physician was not eligible to bill the service. Also, some claims applied deductible and co-insurance incorrectly.
03.16.2022
– Closed
Some claims for drug codes received during the first week of February paid at 100% in error, instead of applying the 20% co-insurance.
02.10.2023
– Closed
E & M Codes 99221-99223, 99231-99236, 99238-99239 denied for place of service code 19 or 22 in error for 2023 dates of service.
01.13.2022
– Closed
The claims containing these two COVID codes were incorrectly routed to Medical Review for review.
01.10.2023
– Closed
Tracers A9500 and A9502 billed for more than 1 unit when being billed with a stress test that includes multiple session/studies are being split into 2 lines to allow 1 unit of the tracer and denying the additional units. The stress test we have seen billed has been 78452 whici is for multiple studies/sessions and the tracer would be given for all studies/sessions.
11.30.2021
– Closed
Incorrect payment of claims billed with nine line items that include clinical lab codes.
11.18.2021
– Closed
Some drug claims processed between 10/26/21 and 10/29/21 were overpaid. These claims were processed with a 2% coinsurance amount instead of 20%. This was an MCS error. The problem was resolved. We are waiting for MCS to provide a list of claims that need to be adjusted.
10.13.2021
– Closed
Claims for CPT Code 0004A, for dates for service prior to 10/08/2021, were denied for Medicare Advantage (MA) Plan in error
07.15.2021
– Closed
Part B claims may deny for prior authorization.
05.06.2021
– Closed
Claims billed with HCPCS codes U0002 and 87635 with HCPCS modifier QW (CLIA waived lab test) denied in error.
04.23.2021
– Closed
There were some OH anesthesia claims with 2020 dates of service that were paid at an incorrect rate. This occurred on some anesthesia claims processed in December 2020 and early January 2021.
03.03.2021
– Closed
Claims submitted with HCPCS code U0005 experienced processing issues. Some were paid but applied to the deductible in error; some denied as routine and for referring physician.
02.05.2021
– Closed
Claims submitted for COVID-19 vaccine administration for patients enrolled in a Medicare Advantage (MA) plan were denied in error.
01.21.2021
– Closed
Claims submitted with Evaluation & Management (E/M) services that included CPT modifier 25 were erroneously denied.
01.21.2021
– Closed
Claims submitted for the Pfizer-Biontech Covid-19 Vaccine Administration (First Dose) are denying in error when billed in place of service 60 (Mass Immunization Center).
07.29.2020
– Closed
The existing requirements related to Skilled Nursing Facility (SNF) consolidated billing (CB) remain in place during the public health emergency (PHE). The telephone evaluation and management (E/M) services are not excluded from SNF CB because the service when rendered via telehealth would not be coverable at all under normal circumstances. Due to the waivers during the PHE, these services are payable and should be excluded from SNF CB. Services submitted have been denied or recouped.
07.17.2020
– Closed
CPT code 0518F and other codes were included in a range of codes that hit an edit in error. Additional documentation request (ADR) letters were sent to providers in error requesting documentation. The edit should only send ADRs on category III codes and end in 'T' when no documentation is sent with the claim.
07.14.2020
– Closed
COVID lab tests were denying against our routine DX edit in error. This was corrected and denials for this would no longer happen as of 07/15/2020 as tech got an email about the same issue and corrected last week.
04.17.2020
– Closed
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.
04.17.2020
– Closed
HCPCS code J3301 was added to the Self-Administered Drug list in error. This caused claims to deny stating "No coverage when self-administered."
04.16.2020
– Closed
We are researching telehealth (audio and visual) claims denying for modifier 95. No provider action needed at this time.

**NOTE: Providers who conduct audio-only communication (no video or visual) may bill CPT codes 98966-98968 and CPT codes 99441-99443. It is not necessary to append the 95 modifier to these telephone codes, as these are not face-to-face services.
02.04.2020
– Closed
Denial of debridement of mycotic nails that do not require a class findings modifier.
02.03.2020
– Closed
All anesthesia codes billed with dates of service 01.01.2020 through 02.05.2020 were priced at the incorrect amount.
02.03.2020
– Closed
With the January Release, the type of service for CPT code 77063 changed, but all system indicators were not. This resulted in erroneous denials for invalid procedure code and place of service. Services that paid applied to deductible or co-insurance in error. In Kentucky, some claims billed with CPT modifier 26 denied for missing the mammogram certification number, which is not required for an interpretation.
01.21.2020
– Closed
Payment for CPT codes 80061, 82465, 84478 and 83718 (KY only) was reduced in error.
12.19.2019
– Closed
CGS determined that in Ohio Part B, we were incorrectly paying HCPCS code A9500 at a flat rate of $121.70 per unit instead of by invoice
11.06.2019- Closed 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.
10.25.2019
– Closed
The myCGS portal remittance advices are masking the Patient Account Numbers with Xs. However, the MLN Matters article MM11289 explains that the first five digits of the patient control number or patient account number (ACNT) will be masked the SSN or HIC are a part of the patient control number or ACNT.
10.17.2019
– Closed
Our processing system added CPT modifier 51 to CPT codes 97140, 97112, and 97530. Services denied due to invalid procedure code/modifier combination.
10.15.2019
– Closed
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.
10.09.2019
– Closed
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.
01.24.2019
– Closed
A system edit allowed the payment of vaccine administration codes when the vaccine was not submitted on the claim. This has resulted in overpayments.
01.24.2019
– Closed
Based on expanded coverage for Intensive Cardiac Rehabilitation (ICR) provided by the Bipartisan Budget Act (BBA) of 2018, the Centers for Medicare & Medicaid Services (CMS) has added several diagnosis codes for chronic heart failure to the national coverage determination (NCD) for ICR services.
01.24.2019
– Closed
Claims submitted with CPT codes 96130-96139 were denied in error for some providers indicating, "This service is not allowed by this type of provider."
01.17.2019
– Closed
Due to a technical issue at the Common Working File (CWF), a number of beneficiary records have been unintentionally blocked. CWF has identified the affected Medicare IDs and is working to correct the problem.
01.18.2019
– Closed
The Functional Reporting requirements of reporting the functional limitation non-payable HCPCS G-codes and severity modifiers on claims for therapy services have been discontinued, effective for dates of service on and after January 1, 2019. Outpatient therapy services with 2019 dates of service billed without G-codes have been denied in error.
01.10.2019
– Closed
The Medicare Part B payment allowances for HCPCS code Q2038 (flu vaccine) is not yet available.
12.13.2018
– Closed
CR10473 added CPT code 36516 to the editing criteria for NCD 20.5 because CPT code 36515 was deleted. With this addition, CPT code 36516 may be allowed if billed for apheresis, which is outside the National Coverage Determination (NCD). Since this is outside of NCD editing, services were incorrectly denied.
10.29.2018
– Closed
All claims for MolDx procedures were required to include the MolDx ID. There was a recent change to this policy that excludes the professional component (CPT mod 26)
10.24.2018
– Closed
An audit that denies CPT codes with a 'ZZZ' global period when the primary code is not billed was inadvertently disabled from September 6 - October 24, 2018. Codes that should have denied were paid in error.
10.24.2018
– Closed
Based on CR 10494, mass adjustments were done to correct the remittances for Qualified Medicare Beneficiary (QMB) claims that were processed between 10/2/17 and 12/31/17. There is a small volume of therapy claims that paid originally but were denied in error on the adjustment.
10.10.2018 Electronic Claims rejecting on the Front End on the 277CA report for diagnosis codes effective 10/1/2018
08.23.2018 – closed System is denying service as not medically necessary as a result of an error with the ICD-10 code
08.16.2018 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.
07.20.2018 A limited number of claims are failing a system audit regarding the patient's name being a mismatch to the patient's identifier.
07.19.2018 Part B Medical Review letters submitted to Part B providers with wrong denial message. The issue impacted about 30 providers that had reviews completed for Evaluation and Management codes in June 2018.
07.05.2018 The Ohio Part B batch for July 2, 2018, failed resulting in no Medicare payment being issued today.
07.02.2018 myCGS portal Greenmail letters have not been delivered

06.20.2018

A system edit has been turned off that was rejecting and denying claims for certain electrocardiographic services.
05.30.2018 CPT codes 0449T and 0450T were to be end dated on a Category III CPT code edit. TOS F (Ambulatory Surgical Center) and TOS 8 (assistant-at-surgery) were mistakenly left as active.
04.19.2018 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.
04.06.2018 Our processing system is denying codes for mismatch MolDX/no MolDX ID submitted on the claim.
03.16.2018 Payers secondary to Medicare aren't able to process some of your direct billed claims due to patient responsibility deductible and coinsurance amounts on the Medicare Remittance Advice (RA) showing zero. Claims automatically crossed over from Medicare to secondary payers aren't impacted.
02.28.2018 Change Request (CR) 10262 addressed the January 2018 CWF update to Skilled Nursing Facility (SNF) Consolidated Billing edits. As a result, changes to the editing inadvertently are causing claims for non-therapy, ambulance services to or from dialysis facilities and physicians professional services to deny in error. Refer to MM10262 for additional information.
02.28.2018 CMS is instructing contractors to hold claims for dates of service in 2018, submitted for therapy services and containing HCPCS modifier KX, until further notice.
02.27.2018 The provisions affecting outpatient therapy services expired 12/31/2017. The new provision required the continued submission of HCPCS modifier KX for services in excess of the prior therapy cap amount for claims with dates of service on and after January 1, 2018. Due to a systems issue, services billed with HCPCS modifier KX in excess of the prior therapy cap amount were denied.

CR 10531 also affects payment of 2018 services rendered by Ambulance suppliers.

Additional, MPFS claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018.
02.12.2018 The Interactive Voice Response (IVR) system is not calculating the QMB deductible and coinsurance amounts correctly.
01.25.2018 Effective for claims with line item dates of service on and after January 1, 2018, contractors shall not bundle or roll up individually billed lab test HCPCS code to a lab panel HCPCS code or an ATP code.
01.17.2018 Claims held due to the January 2018 release

Back to the top of the page Top

spacer

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