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.


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Claim Denial Data

Claims may be accepted as filed by Medicare systems but may be denied. CMS and CGS have established claim level editing to ensure services that should not be paid are appropriately denied. Many denials are due to reasons such as not meeting medical necessity; frequency limitations; and even basic coding mistakes.

Denials are subject to Appeal, since a denial is a payment determination. There are, however, some denials that can be avoided.

Below is a list of the monthly top denial reasons. Refer to resources available to you to avoid future denials.

Top Claim Denials

Kentucky Ohio Description Resource/Reference

# of Denials:
21,385

# of Denials:
79,505

Duplicate Service

Duplicate claims must be avoided:

  • Check the status of ALL claims before resubmitting
  • Submit multiple same services provided on same date on ONE claim
  • Use appropriate modifier to avoid duplicate denials (e.g., 50, RT, LT)
  • When resubmitting services initially rejected (message code MA130), DO NOT include services that were previously paid
    • For example: A claim is submitted with three line items. Two of the services are paid; one is rejected because the CPT code was invalid. When resubmitting a new claim with the corrected CPT code, do not include the two services previously paid, as they will deny as duplicate.
  • It is also possible that a lab or radiology service has been paid by another contractor to a different provider
    • Be sure to consider services provided by other providers. Review the patient's medical records in full.

ANSI Reason or Remark Code: 18/54/N347

# of Denials:
21,188

# of Denials:
65,591

Non-Covered by this Contractor

Before submitting claims to CGS always check patient eligibility to ensure claims are submitted to the correct payer. Updates made to patient files could cause an overlap in dates/contractors resulting in this type of denial.

  • Refer to the Eligibility section of the myCGS User Manual for navigation steps for using myCGS to check patient eligibility
    • Patient may be enrolled in a Medicare Advantage (MA) plan.
    • Also, refer to the Inpatient section to determine if the service was provided while the patient was registered as inpatient hospital or in a skilled nursing facility (SNF) stay
  • The Interactive Voice Response (IVR)PDF is another option

Also, be sure to submit Part B services to Part B; Part A services to Part A.

ANSI Reason or Remark Code: 109/N104/190/N106 N538

# of Denials:
37,039

# of Denials:
25,383

Non-Covered due to Medical Necessity / Payment Adjusted due to Frequency/Benefit Maximum Reached/Services Not Documented

Some services are processed according to a Local Coverage Determination (LCD) and its accompanying Billing/Coding Article. These resources identify coverage criteria, frequency and other limitations, coding guidelines, and medical necessity. Always refer to the LCDs/Medical Policies webpages to check for an LCD.

ANSI Reason or Remark Code: N115

# of Denials:
9,416

# of Denials:
32,168

Payment is Included in Another Service Previously Adjudicated

Edits prevent our system from paying services that may be included in other services.

  • Verify whether service must be billed with other services. This would apply to "add onExternal Website" codes, for example.
  • Check definition of CPT/HCPCS codes to determine whether the code can be separately billed
  • Refer to the Correct Coding Initiative (CCI) guidelines to see if codes are "bundled" into other services
  • The status of some CPT/HCPCS codes prevent them for being separately paid
    • Services with a status 'B' are always bundled, as payment is included in other services
    • The status assigned to codes paid from the Medicare Physician Fee Schedule (MPFS) can be reviewed on the CMS Physician Fee Schedule Look-Up ToolExternal Website.

ANSI Reason or Remark Code: N20/B15

# of Denials:
9,241

# of Denials:
29,048

Code Submitted is for Reporting Purposes Only

Some providers are REQUIRED to participate in reporting programs. One method of participating is to submit non-payable codes on claims. The non-payable codes are captured by CMS or our processing system to determine whether the provider successfully reported. In some cases, to determine if an incentive is paid to the provider. In others, so that data can be captured in order to make future changes to the Medicare program.

Programs involved in submitting codes for reporting purposes include:

NOTE: Because reporting is a requirement, this denial is not one that can be avoided.

ANSI Reason or Remark Code: N620

# of Denials:
3,136

# of Denials:
28,790

Provider Not Certified/Enrolled/ or Eligible to Perform or Order/Refer the Service

State scope of practice determines the services providers are allowed to perform, order, and refer. Please refer to this information for specialty-specific details.

Everything regarding credentialing is available to you on Provider Enrollment webpage!

ANSI Reason or Remark Code: N90, MA13, N574

# of Denials:
8,214

# of Denials:
24,364

Non-Covered due to Statutorily Excluded/Routine Service/Service Performed with Preventive Exam

Statutorily excluded services are services that, by law, Medicare cannot pay for. This includes services:

  • Considered routine in nature
  • That do not meet the requirements of a Medicare benefit category
  • Not reasonable and necessary under 1862 (a)(1)
  • Statutorily excluded from coverage on ground other than 1862(a)(1)

Generally, providers are not required to submit claims to Medicare for statutorily excluded services. There are times, however, when the patient requests these services be submitted in order to obtain a denial for secondary insurance purposes. In this case, submit statutorily excluded services with HCPCS modifier GY.

The Advance Beneficiary Notice of Non-Coverage (ABN)External Website, while not mandated, may be provided to Medicare patients as a courtesy, to inform them of their financial responsibility for services that are statutorily excluded from Medicare benefits. The updated ABN form is located at Beneficiary Notices Initiative (BNI) | CMSExternal Website.

Refer to the Correct Coding Initiative (CCI) guidelines to see if codes are "bundled" into other services and if a modifier can be billed to bypass editing.

ANSI Reason or Remark Code: N425

# of Denials:
6,081

# of Denials:
20,885

Medicare is the Secondary Payer

When Medicare is secondary, the primary payer must be billed first

ANSI Reason or Remark Code: 22/MA16/N36

# of Denials:
5,265

# of Denials:
14,260

Expense Incurred Prior to Coverage/After Coverage Ended

Before submitting claims to CGS always check patient eligibility to ensure there is Part B coverage. Also, verify there have been no lapses in coverage.

ANSI Reason or Remark Code: 26

# of Denials:
2,879

# of Denials:
15,350

Patient is Enrolled in Hospice

Patients waive Medicare Part B payments for professional services related to the terminal prognosis when hospice coverageExternal Website is selected. 

  • Exception for professional services of an independent attending physician not employed by the hospice
    • Submit service with HCPCS modifier GV
  • Services unrelated to terminal prognosis may be reimbursed
    • Submit service with HCPCS modifier GW

Allow front-office staff access to myCGS to verify patient eligibility. Check the Eligibility section of the myCGS User Manual for step-by-step instructions on checking for hospice periods.

ANSI Reason or Remark Code: B9

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