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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

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