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 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

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.

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.
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 website.
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.
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.
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.

Part B – Browse by Specialty

TIP: Click on an arrow or heading to access more content under each topic.

Ambulance

Access guidance for ambulance services through the CMS website:

Ambulatory Surgery Center

Access these resources for CMS-level guidance regarding coverage and claim submission guidelines for Ambulatory Surgical Centers (ASCs):

Anesthesia & Pain Management

Access these resources for CMS-level guidance regarding coverage and claim submission guidelines regarding anesthesia and pain management services:

CMS Anesthesiologists Center Web page
- Anesthesia Conversion Factors
CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12
- Qualified non-physician anesthetists: section 140
- Calculating anesthesia time and units: section 140.3.2
- Supervision and multiple anesthetists: section 140.4

Chiropractic Medicine

Access these resources for CMS-level guidance regarding coverage and claim submission guidelines for chiropractic services:

Hematology/Oncology

Helpful resources for hematology/oncology practices:

CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 17
- Payment for drugs and biologicals: sections 10-30
- Discarded drugs: section 40
- Self-administered drugs: section 80.5, and refer to the CMS Medicare Coverage Database for the list of drugs CGS has deemed to be "usually self-administered"
- Requirements for Erythropoiesis Stimulating Agents, including required modifiers: sections 80.8-80.12
CMS Medicare Claims Processing Manual (Pub. 100-04) chapter 13
- Radiation Oncology: section 70
CMS Medicare Benefit Policy (Pub. 100-02), chapter 15
- Unlabeled use for Anti-Cancer Drugs: section 50.4.5
- Immunosuppressive Drugs: 50.5.1
- Erythropoietin (EPO): 50.5.2
CMS Drug & Biological Fee Schedules
Medicare Program – JW and JZ-Modifier-FAQs
Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy

IDTF

Access these CMS resources for additional information for IDTFs:

CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 35
Physician supervision requirements for diagnostic tests:
- Levels of supervision are defined by CMS, in the Medicare Physician Fee Schedule Database (MPFSDB). For definitions of the levels, refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 23, in the Addendum-MPFSDB Record Layouts (see field 31A)
- Access the CMS Physician Fee Schedule look-up tool to identify the supervision indicator for specific CPT and HCPCS codes
Independent Diagnostic Testing Facility (IDTF) Performance Standards

New to Medicare?

Welcome to Medicare! In addition to the resources below, here are some key resources from the CMS website to help you get started:

Are you a new Medicare Part B provider or staff member? CGS is here to help, and we welcome you to the Medicare program. Please take a tour of the New Provider Resource Center. CGS developed this page with you providers in mind and compiled resources from far and wide. Given these resources, your journey through the Medicare Part B world is sure to be simplified!

We encourage all providers to become familiar with the Centers for Medicare & Medicaid Services (CMS) website and the CGS website to find answers and resources relevant to your Medicare needs.

Education

The primary goal of the Provider Outreach & Education (POE) program is to reduce the Comprehensive Error Rate Testing (CERT) error rate by giving Medicare providers timely and accurate information they need to understand the Medicare program, be informed about changes, and submit accurate claims. Take advantage of Webinars, Ask-the-Contractor Teleconferences (ACTs), Face-to-Face Training, self-paced Online Education Courses (OECs) and more to stay abreast of Medicare changes and updates.

Part B Provider Outreach and Education Site

CMS hosts regular and ongoing teleconference calls for the provider community on various topics. Calls are free. We encourage providers to take advantage of these educational opportunities to receive Medicare information from CMS Subject Matter Experts. Register to receive notices about upcoming Open Door Forums on the CMS website.

Join the Electronic Mailing List

By taking a few simple steps you can register to receive immediate updates on all Medicare information including Medicare publications, important updates, educational opportunities and so much more. The electronic mailing is a free service that guarantees receipt of the latest Medicare news and other time-sensitive information.

Join the Electronic Mailing List here.

Self-Service Technology- myCGS, IVR, and Customer Service

There are instances when a Customer Service Representative may not be available to assist with your inquiry. CGS requires providers to use Self-Service Technology for simple transactions, such as eligibility, deductible, Medicare Secondary Payer information, claims status, and outstanding check information. This allows our Customer Service Staff to be available when you need dedicated assistance for your complex issues. If your inquiry cannot be resolved through self-service technology, you may reach a customer service representative during normal business hours.

myCGS is the latest in self-service technology, offering the providers the ability to check claim status, eligibility, Medicare Secondary Payer information, Part B Deductible/Therapy Cap limitations, remittance notices, and financial information.

To register for this free web portal, please see:

myCGS for Part B

The IVR is the telephone information system, and is available during and outside normal customer service hours, with brief periods of downtime for system maintenance and mainframe availability. Use the IVR to order duplicate remittance notices, as well as obtain the Medicare Part B deductible status, eligibility, Medicare Secondary Payer information, fee schedule information, denial reasons, outstanding check amounts, National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) validation and other claim processing information.

Please Note: You will need your billing NPI, PTAN, and the last five digits of your company's tax identification number (TIN) in order to utilize myCGS, the IVR, or when speaking to a Customer Service Representative.

IVR User Guide (J15 Kentucky & Ohio)

For complex inquires that cannot be handled via the IVR and require the assistance of a Customer Service Representative, providers may call our Provider Contact Center.

1-866-276-9558

The Online Help Center allows you to submit inquires electronically to our customer service staff. It is important to note that you should not submit inquiries or comments through this system that contain sensitive personal information (e.g., social security numbers, tax ID numbers, beneficiary numbers, claim information, etc.) as this method of submitting an inquiry is unsecured and unencrypted. In addition, also note that it may take up to 45 days to respond to your electronic inquiry.

Part B Online Help Center

Part B Online Help Center

Electronic Data Interchange (EDI)

Requirement for Electronic Claim Submission

Submitting claims electronically reduces the reimbursement time by half and improves cash flow. For electronic claims, the minimum amount of time Medicare Contractors must hold claims before releasing payments is only 14 days. Paper claims have a 29-day payment floor from the date of receipt. We encourage all providers to take advantage of the benefits of EDI.

The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be submitted electronically. There are a few exceptions to this requirement. Please complete the Self-Assessment for ASCA in order to determine your qualifications.

Free software

We offer free software in order to submit your Medicare Claims electronically. PC-ACE Pro32 allows you to enter patient information, claim information, procedure file information, and create summary reports from submissions of electronic claims. Details of the software, including download information, are available at the following links:

Part B EDI PC-ACE Pro32 Software

Printing Remittance Advices (RAs)

Medicare Remit Easy Print (MREP) software is free and allows you to view and print HIPAA-compliant Remittance Advices (RAs). You may view and print as many or as few claims from each RA as you like. This will be especially helpful when you need to print only one claim from the remittance advice when forwarding the claim to a secondary payer. This software can save you time resolving Medicare claim issues.

Part B Easy Print Software

More Information about EDI

These benefits and other valuable resources such as EDI contact information are available at the following links:

Part B EDI Homepage

Forms

In an effort to simplify your transactions with Medicare, CGS offers the convenience of a one-stop shop for all the Part B Forms. Forms available from this link include the Reopening Adjustment Request Form, Redetermination Request Form, Offset Request Form, Overpayment Refund, a link to all CMS Forms and more.

Part B Forms

Frequently Asked Questions (FAQs)

You have questions; CGS has answers! Choose from a variety of topics, including Electronic Data Interchange, Medicare Secondary Payer, CMS FAQs and more.

Part B Frequently Asked Questions

Claim Submission

Our goal is to help you submit claims correctly the first time. We are continually adding resources and educational opportunities geared toward identifying common claim submission errors and resolving such issues. Refer to these helpful tools for more information, and remember to check "Browse by Specialty" and "Browse by Topic" for more specialized assistance:

Modifier Finder Tool

We often receive inquiries from providers about claim denials and proper modifier usage. To better assist with these types of inquiries, CGS designed the Part B Modifier Finder tool to aid Medicare providers in using modifiers correctly. You may search this database by modifier, keyword, or, if you wish, you may also view the entire listing of modifiers, their definitions, and additional billing information by selecting the "Show all Modifiers" option.

Give the Modifier Finder Tool a try

Medicare Claim Review Programs and Bundling Edits

National Correct Coding Initiative (NCCI) edits, Medically Unlikely Edits (MUEs), Comprehensive Error Rate Testing (CERT) program, Recovery Audit Contractor (RAC), and the CGS Medical Review (MR) Department: CGS encourages providers to become familiar with these review programs as all claims are subject to review by at least one or more of these programs.

National Correct Coding Initiative (NCCI) & Medically Unlikely Edits (MUEs):

National Correct Coding Initiative (NCCI) edits are designed to promote correct coding by identifying CPT and HCPCS codes that have component parts (other CPT and HCPCS codes) and code combinations that are mutually exclusive. NCCI is a national initiative, and code pairs associated with NCCI edits are available on the CMS website. Edits are updated as often as quarterly, and there are exceptions allowed for some code pairs.

Column I codes identify the major procedure ("parent codes"), and the associated Column II codes are the component codes.
Code pairs with indicator "0" may not be reimbursed separately.
Code pairs with indicator "1" may be reimbursed separately if documentation supports that the service is separately identifiable and medically necessary. For exceptions to NCCI edits: submit the appropriate modifier and maintain supporting documentation. Refer to the CGS Modifier Lookup tool for more information.

Medically Unlikely Edits (MUEs) are also a national initiative and were designed to reduce errors on submitted claims. MUEs set the maximum units of service providers would report in most circumstances for a single beneficiary on the same date of service. Not all codes have MUEs. Most MUEs are published; however, CMS does not publish all MUE values.

More information about NCCI and MUE, and the edits associated with both programs, is available on the CMS website.

Comprehensive Error Rate Testing (CERT) Program

The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to produce national, contractor-specific, and service-specific paid claim error rates. Find CERT information and resources here.

Part B CERT Page

The CERT Claim Identifier Tool allows you to obtain the results of their CERT review for your office or practice. You may search this database by using the Claim Identifier (CID).

CERT Claim Identifier Tool

Medical Review

Do you have questions about the Medical Review process, how to contact the Medical Director, where to find your Local Coverage Determinations (LCDs), or documentation tips and guidelines? Check out the Medical Review link for more information.

Part B Medical Review

Recovery Auditor (RA)

The Medicare Modernization Act of 2003 (MMA) mandated that the Centers for Medicare & Medicaid Services (CMS) establish the Recovery Audit Contractor (RAC) program as a three-year demonstration. The demonstration began March 2005 in California, Florida, and New York. In 2007, the program expanded to include Massachusetts, Arizona, and South Carolina before ending on March 27, 2008. The success of the demonstration resulted in the passage of legislation in the Tax Relief and Healthcare Act of 2006, Section 302, which required CMS to establish a National RAC Program by January 1, 2010.

The Medicare Fee for Service (FFS) Recovery Audit Program's mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers, so that the CMS can implement actions that will prevent future improper payments in all 50 states. Recovery Audit Contractors are known as Recovery Auditors (RAs). The RA for each jurisdiction (state) is determined based on where the services were rendered.

Region 1

States – Ohio, Kentucky, Indiana, Michigan, New York, Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut

Performant Contact Information

Telephone number: 1.866.201.0580
Performant website

E-mail address: info@performantrac.com

Remittance Advices and Payments

Remittance Advices: At first, you may wish you had a secret decoder ring to decipher your Medicare Remittance Advices (RAs).

Codes on your RAs are the keys to deciphering payments, denials, and other important information about your submitted claims. RAs include two types of codes that explain how your claims were processed: Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs). Access the Washington Publishing Company's websitefor a complete list of CARC and RARC codes.

Payments

Medicare reimburses many (but not all) types of services based on fee schedules.

The Medicare Physician Fee Schedule (MPFS) is the basis for reimbursement for many services.
- Look up the MPFS amounts and other helpful reimbursement information for specific CPT and HCPCS codes on the CGS website (using our helpful tool) or directly from the CMS website.
Other fee schedules used to calculate reimbursement for Medicare claims include:
- Ambulance Fee Schedule
- Ambulatory Surgical Center Fee Schedule
- Clinical Laboratory Fee Schedule
- Reimbursement for drugs & biologicals: Average Sales Price (ASP)

Ophthalmology & Optometry

Access guidance for optometry and ophthalmology professionals through these links:

CGS Local Coverage Determination L33944, "Blepharoplasty"
CMS Medicare Benefit Policy Manual (Pub, 100-02), Chapter 15, Section 30.4 and Section 280.1
MLN Products – Medicare Vision Services
Office of Inspector General Report: Medicare Payments for Drugs Used to Treat Wet Age-related Macular Degeneration

Other Specialty

Find a variety of resources on this web page that apply to multiple specialties or specialties other than those listed in the "browse by" section of our website. General resources include:

Payment methodology for nonphysician practitioners: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12
- Physician assistants: section 110
- Nurse Practitioners and Clinical Nurse Specialists: section 120
- Nurse-Midwife services: section 130
- Clinical Social Workers: section 150
- Psychologists: sections 160 and 170

Podiatry

Access guidance for podiatric services through the CMS website:

Guidelines for "foot care": Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 290 and subsequent sections
National Coverage Determination: "Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS) (aka Diabetic Peripheral Neuropathy"

Radiation Oncology

Access guidance for radiation oncology services through the CMS website:

Radiology

Access guidance for radiology services through the CMS website:

Multiple interpretations of the same X-ray or EKG, and multiple X-rays or EKGs furnished on the same date of service: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 13, section 100.1
Multiple Procedure Payment Reduction (MPPR) on the Professional Component (PC) of Certain Diagnostic Imaging Procedures
Payment Reduction for Computed Tomography (CT) Diagnostic Imaging Services
Payment Reduction for X-Rays Taken Using Film
Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)
Physician supervision requirements for diagnostic tests:
- Levels of supervision are defined by CMS, in the Medicare Physician Fee Schedule Database (MPFSDB). For definitions of the levels, refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 23, in the Addendum-MPFSDB Record Layouts (see field 31A)
- Access the CMS Physician Fee Schedule look-up toolto identify the supervision indicator for specific CPT and HCPCS codes

Updated: 07.20.2026