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: + |

Claim Submission Error (CSE) Data

Claim Submission Errors (CSEs) result from an editing process that returns electronic and paper claims to the provider as "unprocessable." This occurs if the claim contains incomplete or invalid information.

Returning a claim as "unprocessable" does not mean CGS will physically return every claim you submit with incomplete or invalid information. The term "Return to Provider" or "RTP" is used to refer to the many processes utilized by CGS for notifying you that your claim cannot be processed. The MA130 remark code on the remittance advice (RA) identifies an RTP claim/service.

RTP claims/services have no Appeal rights, as no "initial determination" can be made on an unprocessable claim/service due to the invalid or incomplete information submitted. This means that these claims cannot be corrected through Redeterminations, the first level of the appeals process. In addition, RTP claims/services do not qualify for correction through the Reopenings process. The error(s) found on these claims/services must be corrected and then resubmitted as NEW claims.

Please note that RTP claims/services create unnecessary costs to the Medicare program so should be avoided.

Below is a list of the monthly top RTP error categories. Refer to resources available to you to avoid future billing errors.

Top Claim Rejections

Kentucky Ohio Description Resource/Reference

# of RTPs: 146,064

# of RTPs:
423,202

Procedure Code Invalid on Date of Service

Code claims using current CPT and HCPCS manuals

  • Codes are valid January - December of each year
  • HIPAA requires the use of codes valid the year the service is rendered
    • Services rendered in CY 2022 must be submitted with 2022 CPT/HCPCS codes
    • Don't forget your CY 2023 manuals!

ANSI Reason or Remark Code: M20

# of RTPs: 5,237

# of RTPs: 11,252

Non-Covered by this Contractor

Before submitting claims to CGS always check patient eligibility to ensure claims are submitted to the correct payer. This includes United Mine Workers of America (UMWA) and Medicare Railroad Beneficiaries (RRB).

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

ANSI Reason or Remark Code: N104, N105/N127

# of RTPs: 3,385

# of RTPs: 12,352

Missing/Incomplete/Invalid Ordering/Referring Provider Name and/or Identifier

Some services require ordering/referring provider to be reported on the claim

  • Enter the provider's name and NPI in the electronic equivalent of box 17 and-17b of the CMS-1500 Claim Form
  • Review the CMS-1500 Claim Form / ANSI Crosswalk Job AidPDF for help identifying the fields
  • If information was reported on the claim, verify the physician/practitioner is of a specialty legally allowed to order/refer services for Medicare patients
  • Also verify ordering/referring physician/practitioner is enrolled in PECOS
    • Verifications may be performed by accessing the Ordering/Referring ToolExternal Websiteon the CMS Web site
    • Enter the ordering/referring provider's name on your claim as it appears in the tool.

ANSI Reason or Remark Code: N285/N286

# of RTPs: 2,471

# of RTPs: 9,634

Missing/Incomplete/Invalid Patient Identifier

Be sure to include the correct patient identifier on your claims.

  • The Medicare Beneficiary Identifier (MBI) is the identification number used for processing claims and determining eligibility for services across multiple entities.
  • Use the myCGS MBI Look-Up Tool to obtain a patient's MBI

NOTE: Always bill using the Medicare Beneficiary Identifier (MBI) and name on the red, white, and blue Medicare card.

ANSI Reason or Remark Code: N382

# of RTPs: 2,748

# of RTPs: 8,047

Patient Medicare Identifier / Name Mismatch

Submit the patient's name and Medicare Beneficiary Identifier (MBI) as it appears on their Medicare card

  • Due to a character limit, some Medicare cards don't display patients' full names.
    • According to section 10.2 of the Medicare Claims Processing Manual, Chapter 26External PDF, you should, "Enter the patient's last name, first name, and middle initial, if any, as shown on the patient's Medicare card.
    • Your claims will still process using the name displayed on the patient's Medicare card, even if it isn't their full name.
  • Patient must contact Social Security to make corrections/changes to Medicare card
  • HIPAA does not allow us to verify Medicare IDs

ANSI Reason or Remark Code: 16/MA27/N382

# of RTPs: 1,702

# of RTPs: 8,076

Missing/Incomplete/Invalid Group Practice Information

The complete name, address, NPI, and phone number of the group practice must be entered in the electronic equivalent of box 33 and 33a of the CMS-1500 Claim Form.

Be sure the NPI of the rendering provider relates to the group's NPI.

ANSI Reason or Remark Code: MA112

# of RTPs: 972

# of RTPs: 6,815

Missing/Incomplete/Invalid Rendering/Attending Provider Primary Identifier

When the rendering physician/practitioner is associated with a group practice, his/her NPI must be entered in the electronic equivalent of box 24j of the CMS-1500 Claim Form. The NPI of the group practice must be entered in the electronic equivalent of box 33 and 33a of the CMS-1500 Claim Form. NOTE: Be sure the NPI of the rendering provider relates to the group's NPI.

If the physician is in a solo practice and bills individually, his/her NPI must be entered in the electronic equivalent of box 33 and 33a of the CMS-1500 Claim Form.

ANSI Reason or Remark Code: M79

# of RTPs: 2,378

# of RTPs: 4,129

Missing/Incomplete/Invalid CLIA Certification Number

The Clinical Laboratory Improvement Amendment (CLIA) of 1988 established quality standards for all lab testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed. Labs must apply and obtain a certificate for the CLIA program that corresponds with the complexity of tests performed.

  • Report the 10-digit CLIA certification number for an entity performing CLIA covered services in Item 23 of the CMS-1500 claim form or its electronic equivalent.
  • Services with separate CLIA certificates MUST be submitted on separate claims.
  • Contact the CLIA program with questions or problems with your certification number.

ANSI Reason or Remark Code: MA120/M91

# of Denials:
1,759

# of Denials:
3,098

Missing/Incomplete Primary Payer Information (Medicare is the Secondary Payer)

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

  • Check this article for steps to help you with MSP claims
  • Be sure to send the primary payer information with your claims
    • Refer to the MSP Job Aid for help identifying the fields needed for an electronic MSP claim
    • If billing on the CMS-1500 claim form, attach a LEGIBLE copy of the primary EOB, clearly identifying the insurer. Be sure the patient is identified on each page and to include the glossary section that defines any codes on the EOB.
  • To verify if there is a payer primary to Medicare:

ANSI Reason or Remark Code: N480

# of RTPs: 869

# of RTPs: 3,178

Invalid/Missing Procedure Code/Modifier Combination

When using a modifier, it must be one that is valid with the procedure code.

  • If service requires a modifier, verify that the correct one is used by accessing the Modifier Finder Tool
  • The patient's medical record must support the use of a modifier

The Provider Contact Center (PCC) cannot tell you which modifier to use on a claim, as they do not have your medical records to determine whether the modifier is appropriately documented.

ANSI Reason or Remark Code: MA130

spacer

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