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Top Provider Questions – Claim Submission

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  1. How can I tell if my claims have been received by CGS?

    • There are a few ways to do this.

      1. Call the CGS Interactive Voice Response (IVR) system. The IVR can confirm claim status, and whether the claim is in process, on the payment floor, or paid/denied. The IVR number is 1-866-290-4036.
      2. Use CGS's web portal, myCGS, to confirm this information (you must be a registered user to do this).
      3. If claims are electronically submitted from your office, your clearinghouse/submission software may have information or a confirmation of claims being electronically submitted.
      Reviewed 9/30/2021
  2. Why does it take more than 14 days to process my electronic Medicare claim submissions?

    • The soonest CGS can release a claim for payment is 14 days after the date of submission (this includes the day of submission and 13 days after that date). This is also called the payment floor. However, per the CMS Medicare Claims Processing Manual (Pub. 100-04, chapter 1, section 80.2.1.1), all Medicare Administrative Contractors, including CGS, have up to 30 days to process clean claims without paying interest.

      A clean claim is defined as a claim that does not have any circumstance or defect that would inhibit timely payment from being made. In other words, it is correct, complete, and includes all of the information CGS requires in order to process that claim. If CGS has requested medical records in order to process a claim, that claim is not considered "clean."

      Reviewed 9/30/2021
  3. How do I submit invoice information for an electronic claim?

    • For electronic claims, report this information in the electronic Documentation Field (Loop 2300, NTE Segment (header level) or Loop 2400, NTE Segment (line level)).

      • The name of the drug and the exact dosage administered must appear in the Documentation Field.
        • If the charge matches the actual invoice cost, note "Actual Invoice Cost" in the Documentation Field.
        • If you are submitting a charge greater than the actual invoice cost, please include the following information in the Documentation Field, using these abbreviations:
          • Des = Description/Name of agent (e.g., Des=TC99m MDP)
          • QS = Quantity shipped (e.g., QS=100 mci)
          • TA = Total amount charged for quantity shipped (e.g., TA=$57.40)
          • UP = Unit Price (e.g., UP = $0.57 per mci) (Optional)
          • DG = Dosage given (e.g., DG=25 mci)
      • In lieu of submitting the invoice information, you may use the Paperwork (PWK) process and send a copy of the invoice via fax or mail.
      Reviewed 9/30/2021
  4. Where can I find Place of Service (POS) codes and definitions?
  5. When we submitted roster claims for our annual flu drive, we entered the Rendering provider in Item 24J and the Billing NPI in 33A. Why was our office paid instead of our clinic?
  6. Do I use the new CMS-1500 form for dates of service on and after April 1, 2014?
  7. Does CGS require the reporting of the JW HCPCS modifier for injectable drugs and biologicals for unused portions of a single dose vial?

    • Prior to 01/01/2017, the JW modifier was not required; however, it was available for use if the provider chose to report drug wastage from a single dose vial using the JW modifier.

      Effective 01/01/2017: Drug Wastage and Modifier JW: Per CR9603External PDF, claims for discarded drug or biological amount not administered to any patient, shall be submitted using the JW modifier. Also, effective January 1, 2017, providers must document the discarded drugs or biologicals in patient's medical record. This CR updates the Section 40 – Discarded Drugs and Biologicals of Chapter 17 of the Claims Processing Manual 100-04External PDF.

      Reviewed 9/30/2021
  8. Does wastage include the amount wasted by the pharmacy when the drug is mixed and prepared for dispensing, or does wastage only apply to the amount not used during the administration of the drug?

    • Wastage includes only the amount not used during administration of the drug. The Centers for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual (Pub. 100-04), chapter 17, section 40External PDF, states: "The program provides payment for the amount of drug or biological administered as well as any amount that is discarded up to the maximum amount of the drug or biological as indicated on the vial or package label." Note: There must be an amount that is administered in order for the wastage from the single use vial to be billable in this scenario.

      Reviewed 9/30/2021
  9. How should the wastage amount be documented in the medical record? The amount ordered, the amount dispensed, the amount administered, and the amount wasted? Should we include the reason for the wastage, the time, date and full name of the provider?

    • We encourage you to provide concise documentation in the medical records whether or not they are reporting wastage on their claim. While CGS does not provide specific guidance on the documentation of the wastage, we advise providers to include anything they feel would help clearly document the amount of the single use vial that was administered and the amount that was wastage.

      Reviewed 9/30/2021
  10. Does wastage include drugs used in surgery, IVs, drugs used in anesthesia, drugs used in respiratory therapy and/or medication such as apligraf used in wound care services?

    • Per CR9603External PDF, effective January 1, 2017, use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded for Part B drugs and biologicals and document the discarded drug or biological in the patient's medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded. In regard to apligraf and wound care services, these products are not considered injectable drugs and therefore the JW modifier and wastage guidelines for single dose vials would not apply.

      Reviewed 9/30/2021

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