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DIRECT DATA ENTRY (DDE) MANUAL

1. First two digits of the type of bill GT Grand total of claims currently in process TC Total count of claims in a particular status location AD An adjustment NM Non medical indicates the claim was placed in RTP because of a clerical error MP Medical policy indicates the claim was placed in RTP because of nonclerical error CLAIM COUNT The total claim count for each specific status location TOTAL CHARGES The total dollar amount of charges submitted by the provider for the total number of claims identified in the claim count TOTAL PAYMENT The total dollar payment amount calculated by the system An amount will only show in this column for claims on the payment floor P B9996 ANSI Reason Codes Option 68 This option allows you to view the narrative for the ANSI American National Standards Institute codes ANSI reason codes appear on remittance advices and provide additional information such as provider appeal rights and claims processing determinations 1 From the Inquiry Menu type 68 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF DRG PRICER GROUPER CLAIM SUMMARY REVENUE CODES HCPC CODES DX PROC CODES ICD 9 ADJUSTMENT REASON CODES REASON CODES ENTER MENU SELECTION LO ZIP CODE FILE Ld OSC REPOSITORY INQUIRY 12 CLAIM COUNT SUMMARY 13 HOME HEALTH PYMT TOTALS
2. Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NQUIRY MENU Map 1741 Field Descriptions NPI National provider identifier HIC The beneficiary s Health Insurance Claim Number HICN PROVIDER Not applicable S LOC Status and location code assigned to the claim by FISS TOB OPERATOR ID The type of bill submitted on the CMS 1450 claim form The first two positions are required for a search The third position is optional Identifies the operator ID utilizing the screen FROM DATE From date of service MMDDYY format TO DATE Through date of service MMDDYY format DDE SORT This field is not functional through the Inquiry Menu Refer to the Claims Corrections chapter of this guide for more information MEDICAL REVIEW SELECT First Line of Data HIC Not in use The beneficiary s Health Insurance Claim Number HICN PROV MRN S LOC Medicare provider number assigned to your facility Status location This code is assigned to the claim by FISS Refer to Chapter 1 of this guide for additional information TOB Type of bill The type of bill code submitted on the CMS 1450 claim form ADM DT Admission date The date the beneficiary was admitted for care FRM DT From date of service MMDDYY format THRU DT Through date of service MMDDYY format
3. Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Map 1821 Field Descriptions MENU PC Plan Code For intermediary use only RC Adjustment reason code This field displays the adjustment reason codes HC HIGLAS adjustment reason code This field identifies the HIGLAS Healthcare Integrated General Ledger Accounting System adjustment reason code Wire Claim type The type of claim associated with this reason code Refer to the CLAIM TYPES field above for valid values NARRATIVE Narrative The description for the adjustment reason code Map 1822 Field Descriptions MNT Identifies the last operator who created or revised this screen and the date For intermediary use only CLAIM TYPES The claim types identified for each adjustment reason code Valid claim types are l Inpatient SNF O Outpatient H Home Health CORF A All Claims PLAN CODE REASON CODE Plan Code For intermediary use only Adjustment reason code identifying the reason for an adjustment HIGLAS REASON CODE HIGLAS reason code Used to crosswalk the FISS adjustment reason code to the HIGLAS adjustment reason code CLAIM TYPE NARRATIVE Claim type The type of claim associated with this reason code Refer to the CLAIM TYPES field above for valid values Narrative The description for the adjustment reason code Reason Codes Optio
4. 14 ANSI REASON CODES 15 CHECK HISTORY L6 DX PROC CODES ICD 10 L7 PLEASE ENTER DATA OR PRESS PF3 TO EXIT 19 1A 56 67 68 FI 1B You may also access this screen by typing 68 in the SC field if you are in an inquiry or claim entry screen Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL ore NQUIRY MENU 2 The ANSI Standard Codes Inquiry screen Map 1581 appears MAP1581 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ANSI STANDARD CODES SEL INQUIRY C201135E HH MM SS RECORD TYPE C ADJ REASONS G GROUPS R REMARKS A APPEALS STANDARD CODE T CLAIM CATEGORY S CLAIM STATUS S RT CODE TERM DT NARRATIVE PLEASE ENTER DATA OR PRESS PF3 TO EXIT 3 Type a record type A C G R S or T in the RECORD TYPE field and press Enter to display the ANSI reason codes for that particular record type A Appeals C Adjustment reason G Groups R Reference remarks S Claim status T Claim category 4 Press F6 to page forward through the various ANSI reason codes Press F5 to scroll backwards MAP1581 CGS J15 MAC Part AREGION ACPFA052 MM DD YY XXXXXX SC ANSI STANDARD CODES SEL INQUIRY C201135E HH MM SS RECORD TYPE A G GROUPS R REMARKS A APPEALS STANDARD CODE T CLAIM CATEGORY S CLAIM STATUS S RT CODE TERM DT NARRATIVE A MAOL IF YOU DISAGREE WITH WHAT WE APPROVED FOR THESE S
5. 5 To inquire about other HCPCS codes enter the HCPCS code over the previously entered HCPC and press Enter 6 Press F3 to exit the HCPCS Information Inquiry screen and return to the Inquiry Menu Field Descriptions for Option 14 HCPC Codes Map 1772 Field Descriptions CARRIER Carrier The carrier number assigned to your provider file System generated LOC The two position locality code which identifies the area where the provider is located HCPC Healthcare Common Procedure Coding System The HCPCS code to be reviewed on the screen MOD HCPC Modifier Multiple fees will be identified for the HCPCS code based on the modifier IND HCPC indicator ERR DT Effective date The date the rate became effective MMDDYY format TERM DT Termination date The termination date for the rate listed MMDDYY format PROVIDER The Medicare provider number assigned to your facility DRUG CODE This field identifies whether the HCPCS code is a drug The valid values are E HCPCS is a drug HCPCS is not a drug EFF DATE Effective date The effective date for the rate listed MMDDYY format TRM DATE Termination date The termination date for the rate listed MMDDYY format EFE Effective date indicator This indicator instructs the system to either use the from and through dates of the claim or the system run date to perform edits for this HCPCS Values are F Claim from date R Claim receipt
6. REC DT Second Line of Data SER Received date The date CGS originally received the claim or the date the claim was corrected from the Return to Provider RTP file Selection This field is used to select the claim you wish to view LAST NAME Last name of the beneficiary FIRST INIT First initial of the beneficiary s name TOT CHG Total charge The total charge submitted on the CMS 1450 claim form PROV REIMB Provider reimbursement The amount reimbursed to the provider for an individual claim PD DT Paid date The date the claim will pay for claims in P B9996 or was paid P B9997 For claims in RTP T B9997 this is the date the claim went to the RTP status location For claims rejected R B9997 or denied D B9997 this is the date the claim rejected or denied Second Line of Data continued Cancel date The date the original claim was canceled DAYS Reason code The code assigned by FISS describing what is happening to the claim edit Non payment code The code indicating why payment was not made Values are B Benefits exhausted All other reasons Payment requested Spell of illness benefits refused certification refused failure to submit evidence provider responsible for not filing timely ro Waiver of Liability Workers compensation MSP cost avoided System set for type of bills 322 and 332 MSP Primary Payer NOTE this code displays on home health Requests for Antici
7. T CLAIM CATEGORY S CLAIM STATUS S RT CODE TERM DT NARRATIVE A MAOL IF YOU DISAGREE WITH WHAT WE APPROVED FOR THESE SERVICES Y s a MAO2 IF YOU DO NOT AGREE WITH THIS DETERMINATION YOU HAVE THE R A MA04 110407 SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTITY A MAOS 101603 INCORRECT ADMISSION DATE PATIENT STATUS OR TYPE OF BILL EN A MA06 080104 INCORRECT BEGINNING AND OR ENDING DATE S ON CLAIM A MAO7 110407 THE CLAIM INFORMATION HAS ALSO BEEN FORWARDED TO MEDICAID F A MAO8 110407 YOU SHOULD ALSO SEND THIS CLAIM TO THE PATIENT S OTHER INSU A MA09 110407 CLAIM SUBMITTED AS UNASSIGNED BUT PROCESSED AS ASSIGNED YO A MA10 110407 THE PATIENT S PAYMENT WAS IN EXCESS OF THE AMOUNT OWED YOU A MA100 110407 DID NOT COMPLETE OR ENTER ACCURATELY THE DATE OF CURRENT IL Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL CHARTER 3 INQU RY MENU The ANSI Standard Reason Codes Inquiry screen Map 1582 appears MAP1582 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ANSI STANDARD REASON CODES INQUIRY C201135E HH MM SS MNT SYSTEM 07 02 10 RECORD TYPES ARE C ADJ REASONS G GROUPS R REMARKS A APPEALS T CLAIM CATEGORY S CLAIM STATUS RECORD TYPE A TERM DT EFF DT 010197 STANDARD CODE MA02 NARRATIVE IF YOU DO NOT AGREE WITH THIS DETERMINATION YOU HAVE THE RIGHT TO APPEAL YOU MUST FILE A WRITTEN REQUEST FOR AN APPEAL WITHIN 180 DAYS OF THE
8. and press Enter The ORIG REQ DT field on Page 07 indicates the date CGS requested the additional information Documentation should be mailed no later than 30 days after this date This allows for ample mail time and processing of the documentation when received by CGS Page 07 also identifies the address to which your documentation should be mailed The DUE DATE field is 45 days from the original request date ORIG REQ DT To ensure documentation is received timely providers are required to submit ADR documentation to CGS by day 30 15 days before the DUE DATE Documentation not received by the DUE DATE will result in the claim being denied Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NQUIRY MENU Example FISS Page 07 REPORT 001 MEDICARE PART A 15XXX PVDR NO XXXXXXXXXX DATE MM DD CCYY ADDITIONAL DEVELOPMENT REQUEST BILL TYPE 813 CASE ID 15004XXXXXXXXXXXXXXPAROPR ANYNAME HEALTH CENTER 1111 MAIN ST ANYTOWN IA 52001 1111 WE HAVE REVIEWED THIS CLAIM RECORDS AND FOUND THAT ADDITIONAL DEVELOPMENT WILL BE NECESSARY BEFORE PROCESSING CAN BE FINALIZED TO ASSIST YOU IN PRO THE REQUIRED INFORMATION WE HAVE AORTNE REASON CODES TO THE ACCOMPANYING LIST FOR EXPLANATION OF THE ASSIGNED CODES WE MUST RECEIVE THE REQUESTED INFORMATION BEFORE THE DUE DATE LISTED BELOW OR THE CLAIM J15 Part A PCC P O BOX 20200 NASHVI
9. Aia ie DIRECT DATA ENTRY DOE MANUAL aes A UR MENU CHAPTER 3 OSC Repository Inquiry Option 1A Claim Count Summary Option 56 Field Descriptions for Option 56 Claim Count Summary ANSI Reason Codes Option 68 Field Descriptions for Option 68 ANSI Reason Codes Check History Option FI Field Descriptions for Option FI Check History Dx Proc Codes ICD 10 Option 1B Disclaimer This educational resource was prepared to assist Medicare providers and is not intended to grant rights or impose obligations CGS makes no representation warranty or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of these materials CGS encourages users to review the specific statutes 45 46 49 49 51 52 53 53 regulations and other interpretive materials for a full and accurate statement of their contents Although this material is not copyrighted the Centers for Medicare amp Medicaid Services CMS prohibit reproduction for profit making purposes Created August 22 2014 Ae 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MAN UAL PA NQUIRY MENU Inquiry Menu Options The Inquiries option FISS Main Menu option 01 allows you to e Check the status of submitted billing transactions Locate claims in an ADR Additional Development Request status e View a summary of all claims curren
10. DATA HIC LN FN SEX AND DOB PRESS PF3 EXIT PF8 NEXT PAGE After you press Enter the system will search for the beneficiary s eligibility file If a match is found additional information will display on Map 1751 If no match is found verify that you have entered the correct information make any necessary corrections and press Enter again Information will only display if CGS has processed a claim for the beneficiary If no match is found a claim for the beneficiary has not been submitted processed in FISS by CGS Do not use this option to verify Medicare eligibility because it may not be as current as the CWF Common Working File information that you access via ELGA or myCGS Use option 10 only if you need information about the beneficiary s addressChapter 2 of this guide for information about accessing beneficiary eligibility information 10 Once a match is found with the beneficiary information entered the beneficiary s home address will appear in the ADDRESS and ZIP fields 11 Press F3 to exit and return to the Inquiry Menu Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NGE CHARTER 5 INQUIRY MENU Field Descriptions for Option 10 Beneficiary CWF Screen Map 1751 Page 1 Screen Example MAP1751 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ELIGIBILITY DETAIL INQUIRY C20112WS HH MM SS HIC CURR XREF HIC PREV XREF HIC TRANSFER HI
11. DATE YOU RECEIVE THIS NOTICE PRESS PF 3 EXIT PF7 PREV PAGE 7 Press F7 to return to Map 1581 8 To display one specific ANSI code type the appropriate record type e g A C G R S or T in the RECORD TYPE field Type the ANSI Standard Code that you wish to view in the STANDARD CODE field and press Enter The Map 1582 will display MAP1581 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ANSI STANDARD CODES SEL INOUIRY C201135E HH MM SS AD SON G GROUPS R REMARKS A APPEALS T CLAIM CATEGORY S CLAIM STATUS RT COD RM D NARRATIVE MAP1582 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ANSI STANDARD REASON CODES INQUIRY C201135E HH MM SS MNT SYSTEM MM DD YY RECORD TYPES ARE C ADJ REASONS G GROUPS R REMARKS A APPEALS T CLAIM CATEGORY S CLAIM STATUS RECORD TYPE E TERM DT EFF DT 2 010195 STANDARD CODE Bl NARRATIVE NON COVERED VISITS Field Descriptions for Option 68 ANSI Reason Codes Map 1581 Field Descriptions RECORD TYPE The record type for the ANSI standard code Valid values are A Appeals G Groups S Claim Status C Adjustment Reasons R Reference Remarks T Claim Category STANDARD CODE The standard code within the above record type S The selection field used to view the entire narrative of a specific ANSI code RT The record type of the ANSI code being selected CODE The ANSI code being selected oeoa Coo
12. DT EFF DT TRM DT EFF DT TRM DT Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MAN UAL N YIRY MENU To view revenue code information type the revenue code in the REV CD field and press Enter MAP1761 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX Sc REVENUE CODE TABLE INQUIRY C201135E XX XX XX EFF DT 070166 IND F TERM DT NARR PHYSICAL THERAPY GENERAL CLASSIFICATION PHYSICAL THERP ALLOW HCPC UNITS RATE TOB EFF DT TRM DT EFF DT TRM DT EFF DT TRM DT EFF DT TRM DT 11x Y 070166 V N N 12X Y 070166 010199 Y 070198 N 13X Y 070166 Y 010199 Y 070166 N 14X N V N N 18X Y 070166 V N N 21X Y 070166 V N N 22X Y 070166 010199 Y 070198 N 23X Y 070166 Y 010199 Y 070166 N 32X Y 070166 100199 Y 070166 N 33X Y 070166 Y 100199 Y 070166 N PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF6 SCROLL FWD ma To see all of the revenue code information for all types of bill TOB press F6 to scroll forward 4 To make additional inquiries simply enter a new revenue code over the previously entered 5 code and press Enter If you enter a new 3 digit revenue code over the previously entered code the first digit must be a zero or enter the 3 digit revenue code in the first 3 positions and delete the 4th digit before pressing Enter Press F3 to exit the Revenue Code Table Inquiry screen and return to the Inquiry Menu Field Descri
13. Health Insurance Claim Number HICN Identifies the HICN assigned RECEIPT DATE Identifies the actual receipt date This is automatically entered by FISS TOB Type of Bill Identifies the type of bill that applies to the claim Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL FER NQUIRY MENU Map 171D Field Descriptions CHARTERS STATUS Identifies the claim s status in the system P D R S or T LOCATION Further identifies the claim s location in the system TRAN DT Transaction Date Identifies the date of the latest update activity STMT COV DT Statement Covers Date Identifies the beginning date of service TO Statement Covers To Date Identifies the ending date of service PROVIDER ID Provider Number Identifies your facility s National Provider Identifier NPI BENE NAME Beneficiary Name Identifies the name of the beneficiary NONPAY CD Non Pay Code Identifies the reason for Medicare s decision not to make payment Valid values are B Benefits exhausted N All other reasons P Payment Requested R Spell of illness benefits refused certification refused failure to submit evidence provider responsible for not filing timely ro Waiver of Liability W Workers Compensation X MSP cost avoided MSP Primary Payer GENER HARDCPY Generate hardcopy Instructs system to generate a specific type of hard copy document Valid values are 2 Medical ADR
14. ONE WAS ISSUED TO THE ENEFICIARY HIS EDIT SELECTS CLAIMS DUE TO PREVIOUS DENIALS FOR THIS BENEFICIARY MEDICARE REQUIRES THAT MEDICAL RECORD ENTRIES FOR SERVICES PROVIDED ORDER BE AUTHENTICATED BY THE AUTHOR THE METHOD USED SHALL BE A HANDWRITTEN ON AN ELECTRONIC SIGNATURE PATIENT IDENTIFICATION DATE OF SERVICE AND OF H W Press F6 to see the remaining reason code narrative that identifies the documentation that you need to submit REASONS 59BX9 REASON CODE NARRATIVES FOR HIC DCN NNNNNNNNNA XXXXXXXXXXXXXXPAR PROVIDER OF THE SERVICE ORDER MUST BE CLEARLY AND LEGIBLY IDENTIFIED ON THE SUBMITTED DOCUMENTATION THE DOCUMENTATION YOU SUBMIT IN RESPONSE TO THIS REQUEST SHOULD COMPLY WITH THESE REQUIREMENTS IF YOU QUESTION THE LEGIBILITY OF ANY SIGNATURE YOU MAY SUBMIT AN ATTESTATION STATEMENT OR SIGNATURE LOG WITH YOUR ADR RESPONSE FOR MORE INFORMATION SEE THE MLN MATTERS ARTICLE MM6698 WHICH CAN BE FOUND AT WWW CMS HHS GOV MLNMATTERSARTICLES OMB CONTROL XXXX XXXX To go back to FISS Page 07 press your F7 key 7 Make a copy of Page 07 and attach it to the top page of your medical record documentation This ensures that the documentation will be matched with the correct claim Mail it to the address listed on Page 07 as soon as possible You may also want to keep a printed a copy of pages 07 and 08 reason code narrative as a aa reference of what was requested and to document when you s
15. SS BENEFICIARY CWF LO ZIP CODE FILE 19 DRG PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 L5 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES 17 ENTER MENU SELECTION 14 PLEASE ENTER DATA OR PRESS PF3 TO EXIT ma You may also access this screen by typing 14 in the SC field if you are in an inquiry or claim entry screen INGU RY MENU The HCPC Information Inquiry screen Map 1771 appears MAP1771 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC HCPC INFORMATION INQUIRY C201135E HH MM SS PAGE 01 CARRIER LOC HCPC MOD IND EFF DT TRM DT PROVIDER DRUG CODE EOFOC ANES TM EFF TRM FV EPA PC BASE Y 5 DATE DATE F RE HT TC VAL P I ALLOWABLE REVENUE CODES HCPC DESCRIPTION PROCESS COMPLETED PLEASE CONTINUE PLEASE ENTER DATA OR PRESS PF3 TO EXIT 3 Use your Tab key to move to the HCPC field and type the HCPCS code Press Enter FISS will automatically insert information in the CARRIER and LOC fields based on your geographic location MAP1771 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc HCPC INFORMATION INQUIRY C201135E HH MM SS PAGE 01 CARRIER XXXXX LOC XX HCPC 83970 MOD IND R EFF DT 010107 IRM DT PROVIDER XXXXXX DRUG CODE EOFOC ANES TM EFF TRM FV EPA PC BASE Y S DATE DATE FRE HT TC VAL P I ALLOWABLE R
16. associated with the beneficiaries claim denial This is an eight position alphanumeric field OLUAC Original Line User Action Code Identifies the original line user action code and is only used when there is a line user action code and a corresponding medical review denial reason code in the Benefits Savings portion of the claim LUAC Line User Action Code This is a 2 position field The 1st position indicates the cause of the denial reason for the specific revenue line see the USER ACT CODE field of this FISS Guide chapter for valid values The 2nd position indicates the reconsideration code A value equal to R indicates that reconsideration has been performed NON COV UNT Noncovered units Contains the number of units that are being denied if applicable NON COV CHRG Noncovered charges Identifies the total of denied rejected noncovered charges for each line item being denied DENIAL REAS Denial Reason Identifies the reason code associated with the denial for the revenue code line OVER CODE Override Code Overrides the system generated ANSI codes from the denial reason code file The valid values are A override system generated ANSI code system default Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL WE CHAPTER 3 INQUIRY MENU Map 171D Field Descriptions ST LC OVER Status location Override Overrides the reason code file status Only us
17. be blank The valid values are 1 Medicaid c 2 BlueCross D 3 Other E 4 None F A Working Aged G B ESRD beneficiary in a 30 month coordination H period with an employer group health plan L Conditional payment Auto no fault Worker s Compensation Public Health Service or other Federal Agency Disabled Black Lung Liability MSP PAYER 2 ID Medicare Secondary Payer Payer 2 ID Displays 1 position alphanumeric code identifying the specific payer If Medicare is secondary this field will be blank The valid values are 1 Medicaid c 2 BlueCross D 3 Other E 4 None F A Working Aged G B ESRD beneficiary in a 12 month coordination H period with an employer group health plan L Conditional payment Auto no fault Worker s Compensation Public Health Service or other Federal Agency Disabled Black Lung Liability Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL hea Map 171A Field Descriptions MENU Fields prior to the start of the revenue code line item information first four rows of information are system generated from Page 01 of the claim PAT REIMB Patient Reimbursement This field identifies the system generated calculated line amount to be paid to the patient on the basis of the amount entered by the provider on Page 03 of the claim in the Due From PAT field PAT RESP Patient Responsibility Identi
18. date D Discharge date OVR Override code This field instructs the system in applying the services towards deductible and coinsurance Values are 0 Apply deductible and coinsurance 5 Rural health clinic or comprehensive outpatient 1 Do not apply deductible rehabilitation facility psychiatric 2 Do not apply coinsurance M Employer group health plan EGHP only used on the 3 Do not apply deductible or coinsurance 0001 total line for Medicare Secondary Payer MSP 4 No need for total charges used for N Non EGHP only used on the 0001 total line for MSP multiple HCPCS for single revenue Y MSP cost avoided code centers Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Eee MENU NQUIE Map 1772 Field Descriptions FEE Fee Indicator The fee indicator received in the Physician Fee Schedule file Valid values B Bundled procedure R Rehab Audiology Function Test CORF Services 669 Space OPH Outpatient Hospital Indicator The outpatient hospital indicator received in the physician fee schedule abstract test file Valid values 0 Fee applicable in Hospital Outpatient Setting 1 Fee not applicable in Hospital Outpatient Setting eo Space CAT PC TC Professional Component Technical Component Valid values are 0 Pay the Health Professional Shortage Area HPSA bonus 1 Globally billed Professional component for this service qualifies for the HPSA bo
19. processing is required 7 force claim to be re edited by medical policy edits in the 5XXXX range 8 claim was suspended via an OCE MED review reason 9 claim has been identified as a first claim review WAIV IND Waiver Indicator Identifies whether the provider has their presumptive waiver status This field is no longer used MR REV URC Medical Review Utilization Review Committee Reversal DEMAND Medical Review Demand Reversal REJ CD Reject Code Identifies the reason code for which the claim is being denied on full claim denials only MR HOSP RED Medical Review Hospice Reduced For hospice claims this field identifies the line item s has been reduced to a lesser charge by medical review Valid values are Y Reduced 7 _ Not reduced ORIG UAC Original User Action Code For intermediary use only MED REV RSNS Medical Review Reasons Identifies a specific error condition relative to medical review There are up to nine medical review reasons that can be captured per claim This field only displays medical review reasons specific to claim level OCE MED REV RSNS OCE Medical Review Reasons Unlabeled Identifies the line number of the revenue code The line number is located above the revenue code field on this Map To move to another revenue code press F6 to scroll down and F5 to scroll up REV Revenue Code HCPC MOD IN HCPCS Code Modifier Valid values
20. same code is listed be sure to review the description effective and m termination dates and use the most current code that applies to the service dates on your claim aa Press F6 to scroll forward through the list of diagnosis codes 4 To make an additional inquiry type the new diagnosis code over the previously entered diagnosis code and press Enter 5 To inquire about a procedure code type the letter P followed by the procedure code in the STARTING ICD9 CODE field and press Enter To review a complete list of procedure codes enter the letter P in the STARTING ICD9 CODE field and press Enter 6 Press F3 to exit and return to the Inquiry Menu Field Descriptions for Option 15 DX PROC Codes ICD 9 Map 1731 Field Descriptions STARTING ICD9 ICD 9 CM code The ICD 9 CM code identifying a specific diagnosis CODE or procedure DESCRIPTION ICD 9 CM description The narrative for the ICD 9 CM code EFFECTIVE TERM Effective termination date The effective and or termination date for the ICD 9 DATE CM code in MMDDYY format Up to three occurrences of dates can appear Adjustment Reason Codes Option 16 This option allows you to view adjustment reason codes and their narratives Use these codes to identify reasons for an adjustment Adjustment reason codes must be submitted on adjustment and cancellation claims when using FISS to submit these type of billing transactions See Chapter 5 of this guide for addit
21. the claim press F3 to return to the claim list Map 1741 You can select a different claim start a new search or press F3 to return to the Inquiry Menu When you view claims within option 12 it is an inquiry only option You cannot enter correct adjust or cancel claims within option 12 You can only view the claim information To enter correct adjust and cancel claims you must use other options in FISS 2 To view claims by a status code or by a status and location follow these steps a On Map 1741 type your facility s NPI number in the NPI field To move the cursor from the HIC field to the NPI field hold down the Shift key and press the Tab key b Tab to the S LOC field and type the status code or the status location that you wish to view and press Enter You may for example want to view claims that are on the payment floor P B9996 Note that FISS automatically inserts one space between the status and the location codes When you view claims by status location code you will most likely be inquiring about claims in the following status locations Status Location Description P B9996 Payment floor P B9997 Processed or paid claim D B9997 Denied claim R B9997 Rejected claim T B9997 Claim needing correction S B6001 Claim selected for an additional development request ADR Any status location code that appears on a claim can be entered into the S LOC field Entering the status l
22. transactions press Enter If you are authorized to view other provider number information branch office you will have access to the PROVIDER field to enter another provider number Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Eee RY MENU law You may also enter a specific status location e g T B9997 in the S LOC field or a category type in the CAT field to narrow the selection MAP1371 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc CLAIM SUMMARY TOTALS INQUIRY C201135E HH MM YY PROVIDER NNNNNN LOC CAT NPI NNNNNNNNNN S LOC CAT CLAIM COUNT TOTAL CHARGES TOTAL PAYMENT 48 389 34 5 722 00 00 00 P a 13 9 9 768 85 00 00 P B7505 TC 20 22 767 48 00 00 P B7505 12 5 4 099 80 00 00 P B7505 11 15 18 667 68 00 00 P_B9996 11 6 6 921 11 5 722 00 S B90M0 1 00 00 00 00 S B9OMO 1 00 00 00 00 1 761 70 00 00 761 70 00 00 1 000 00 00 00 B9997 7 170 20 00 00 T B9997 7 170 20 00 00 B9997 7 170 20 00 00 PROCESS COMPLETED PLEASE CONTINUE PLEASE MAKE A SELECTION ENTER NEW KEY DATA PRESS PF3 EXIT PF6 SCROLL FWD 4 Once the information is displayed you can identify where your claims are within FISS by looking at the S LOC field Option 56 identifies how many claims are in a particular status location The CAT column identifies the first two digits of the type of bill and the category code for each specific status location The
23. viewing Claim Count Summary option 56 or the Claim Inquiry option 12 screens the claim may still appear in status location T B9997 for several weeks until FISS purges suppressed claims to the I status Once you have reviewed the information on option 56 press F3 to exit and return to the Inquiry Menu You can then select 12 Claims from the Inquiry Menu to view the specific claims within each status location Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NQUIRY MENU Field Descriptions for Option 56 Claim Count Summary Map 1371 Field Descriptions PROVIDER Your Provider Transaction Access Number PTAN S LOC Status Location Enter a specific status location code in this field to view the number of billing transactions in that specific status location CGS suggests leaving this blank so you can see the status locations of all the billing transactions currently processing CAT Category Enter a specific category GT TC 13 11 72 or 74 to view the number of billing transaction under that specific category CGS suggests leaving this blank so you can see all claims currently processing See below for the valid CAT codes NPI Your facility s National Provider Identifier NPI number S LOC This identifies the current status location of the claims CAT The Category field identifies different items within the list Valid values are
24. 014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL aes INQUIRY MENU Map 171D Field Descriptions CHARTER 3 OCE OVR Override Overrides the way the OCE module controls the line item Valid values are 0 OCE line item denial or rejection is not ignored 1 OCE line item denial or rejection is ignored 2 External line item denial Line item is denied even if no OCE edits 3 External line item reject Line item is rejected even if no OCE edits 4 External line item adjustment Technical charge rules apply CWF OVR CWF Override Overrides the way the OCE module controls the line item NCD OVR National Coverage Determination Override Indicator Identifies whether the line has been reviewed for medical necessity and should bypass the NCD edits the line has no covered charges and should bypass the NCD edits or the line should not bypass the NCD edits Valid values are NCD edits are not bypassed Y the line has been reviewed for medical necessity and bypasses the NCD edits D the line has no covered charges and bypasses the NCD edits NCD DOC National Coverage Determination Documentation Indicator Identifies whether the documentation was received for the necessary medical service Valid values are Y the documentation supporting the medical necessity was received N the documentation supporting the medical necessity was not received NCD RESP Nati
25. 5 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI XXXXXXXXXX HIC PROVIDER S LOC S B6001 TOB OPERATOR ID XXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS NNNNNNNNA XXXXXX S B6001 XXX 1204XX 1204XX 0119XX 0212XX LASTNAME M 1700 00 39700 s wwnnNNNA XXXXXX S B6001 XXX 1025XX 1025XX 1110XX 0212XX LASTNAME J 300 00 39700 NNNNNNNNA XXXXXX S B6001 XXX 1115XX 1115XX 1215XX 0212XX LASTNAME R 336 00 39700 NNNNNNNNA XXXXXX S B6001 XXX 1019XX 1019XX 1217XX 0212XX LASTNAME T 1000 00 39700 PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD 4 Page 01 of the claim appears Map 1711 DD YY XXXXXX SC HIC 444555666A TOB XXX NPI NNNNNNNNNNN TRANS HOSP PAT CNTL STMT DATES FROM 1025XX TO LAST SMITH ADDR 1 101 MAIN ST 3 CGS J15 MAC Part A REGION INST CLAIM INQUIRY S LOC S B6001 OSCAR XXXXXX PROV TAX SUB 1110XX DAYS COV N C FIRST JAMES 2 ANYTOWN IA 4 C20112WS HH MM SS SV PROCESS NEW HIC TAXO CD CO MI E DOB 01011931 CPFA052 MM UB FORM LTR CARR 5 ADR information is electronically attached to the end of the claim as pages 07 and 08 To view the ADR information type 07 in the PAGE field if your cursor is not already in this field press the HOME button found on your keyboard
26. 7 e Make a copy of Page 07 and attach it to the top page of your medical record documentation Mail the documentation to the address that appears on FISS Page 07 Once received by CGS the documentation is scanned into the Optical Character Recognition OCR software and CGS staff will move the claim from status location S B6001 into status location S M50MR pending review of the documentation If CGS does not receive the requesteds information by day 45 the claim will automatically deny on day 46 and move to status location D B9997 with reason code 56900 and your only recourse for Medicare payment is to request a Reopening Refer to the Reopenings Web page for additional information http www cgsmedicare com parta appeals reopenings html on day 46 CGS will proceed with reviewing the documentation and there is no need to request a Reopening g NOTE If the documentation was received timely by day 45 but the claim automatically denied e CGS s review of your documentation can take up to 60 days from when the documentation was received Once the review is completed the claim is moved to status location S M5CLM for additional processing Missing or Illegible Signature Documentation If during review of your documentation it is determined that a signature is missing or illegible the claim will be re ADRd to status location S B6001 Page 08 will show the Reasons field with 5ADR2 and the narrative will
27. 7 ADR to beneficiary 3 Non medical ADR 8 MSN line item or partial denial 4 MSP ADR 9 MSN claim level or full denial 5 MSP cost avoidance ADR MR INCLD IN COMP Composite Medical Review Included in Composite Rate CL MR IND Complex Manual Medical Review Indicator Identifies if all services on the claim received complex manual medical review Valid values gt The services did not receive manual medical review Y Medical records received and this service received complex manual medical review A Y will display when the OCE FLAGS field on Map 171A displays an M Medical Review changes a HIPPS code N Medical records were not received and this service received routine manual medical review TPE TO TPE Tape to Tape flag Displays the tape to tape flag indicating the system to either perform or skip a function If the value in this field is X the claim data information is not posted to the Common Working File CWF If this field is blank the claim data from the finalized status location P B9997 R B9997 or D B9997 billing transaction did post to CWF Whenever claim data has posted to CWF a cancel or adjustment must be submitted to remove or change this information Valid values and the functions include Transmit To CWF Y Y N N N YYYY N N Print On Remittance Y Y Y N y Y N N N Y N USER ACT CODE User Action Code For intermediary use for med
28. 8 Skilled Nursing Facility Demand Bills 100009 Daily Nursing Visits Are Not Intermittent Part Time 100010 Specific Visits Did Not Include Personal Care Service 100011 Home Health Demand Bills 100012 Ability To Leave Home Unrestricted 100013 Physician s Order Not Timely 100014 Service Not Ordered Not Included In Treatment Plan Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL eee CHAPTER 3 INQUIRY MENU Map 1882 Field Descriptions DENIAL CODE continued 100015 Services Not Included In Plan Of Care 100016 No Physician Certification E G Home Health 100017 Incomplete Physician Order 100018 No Individual Treatment Plan 100019 Other MR INDICATOR Complex manual medical review Identifies whether the service received complex manual medical review Valid values are The services did not receive manual medical review Y Medical records received This service received complex manual medical review N Medical records were not received This service received routine manual medical review PCA INDICATOR Progressive Correction Action Identifies the progressive correction action indicator Valid values are The medical policy parameter is not PCA related and is not included in the PCA transfer files Y The medical policy parameter is PCA related and is included in the PCA transfer files N The medical policy parameter is not PCA related and is not i
29. C C IND LTR DAYS LN FN MI SEX DOB DOD ADDRESS 1 2 3 4 5 6 ZIP CURRENT ENTITLEMENT PART A EFF DT TERM DT PART B EFF DT TERM DT CURRENT BENEFIT PERIOD DATA FRST BILL DT LST BILL DT HSP FULL DAYS HSP PART DAYS SNF FULL DAYS SNF PART DAYS INP DED REMAIN BLD DED PNTS PSYCHIATRIC PSY DAYS REMAIN PRE PHY DAYS USED PSY DIS DT INTRM DT IND PLEASE ENTER DATA HIC LN FN SEX AND DOB PRESS PF3 EXIT PF8 NEXT PAGE Map 1751 Field Descriptions HIC The beneficiary s HICN Health Insurance Claim Number LN Last name of the beneficiary FN First name of the beneficiary MI Middle initial of the beneficiary SEX Sex of the beneficiary F Female M Male DOB Date of birth of the beneficiary MMDDCCYY format DOD Date of death of the beneficiary MMDDCCYY format ADDRESS 1 6 Beneficiary s street address city and state ZIP Zip code for beneficiary s residence The remaining field descriptions are not provided as you should not use the information to verify Medicare eligibility because it may not be as current as the CWF Common Working File information that you access via ELGA Refer to Chapter 2 of this guide for information about accessing beneficiary information using ELGA or myCGS DRG Pricer Grouper Option 11 This option allows you to view specific DRG diagnostic related group assignment and PPS prospective payment system information for inpatient hospital stays as c
30. CAN DT REAS NPC DAYS PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD You can use the following function keys to move within the Claim Summary Inquiry screen and within the different claim pages F3 Exit return to the Inquiry Menu F5 Scroll back through a list of claims or revenue code pages F6 Scroll forward through a list of claims or revenue code pages F7 Move one claim page back F8 Move one claim page forward F10 Move to the left page F11 Move to the right page Shift Tab Move from the right to left in valid fields ex Move from the HIC field to the NPI field Checking the Status of Your Claims Beneficiary Claim History When the Claim Summary Inquiry screen displays your cursor will be located in the HIC field However to check the status of claims you must first enter your facility s NPI Therefore to move the cursor to the NPI field hold down the Shift key and press the Tab key You cursor will automatically move to the NPI field There are two primary ways that you can view the status of your claims using option 12 by beneficiary s HICN or by status location within FISS 1 To view information using a beneficiary HICN follow these instructions a Type your facility s NPI number in the NPI field b Type the beneficiary s HICN in the HIC field Press Enter MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY X
31. CLAIM COUNT column provides the number of claims in that specific status location Refer to the field description for a complete list of CAT codes You may need to press F6 to see the complete list of status locations e In the screen example above this provider can quickly identify There are a grand total GT of 49 claims for a total charge of 48 389 34 and payment amount of 5 722 00 payment floor status location P B9996 The status location P B9996 payment floor has a total count TC of six claims The six claims have a total charge of 6 921 11 and a total payment of 5 722 00 All six claims are type of bill TOB 13X CAT code 13 The status location S B6001 Additional Development Request ADR status has a total count TC of two claims One of the claims is a TOB 12X and one is a TOB 13X CAT codes 12 and 13 The status location T B9997 Return to Provider RTP status has a total count TC of 11 claims All claims are TOB 13X CAT code 13 and all were placed in RTP because of clerical errors CAT code NM e Option 56 only displays claims that are currently processing in FISS Claims that are finalized in the system i e with status locations of R B9997 P B9997 D B9997 are not included within this option In addition option 56 only displays claims by status location code You can use option 56 in conjunction with option 12 if you want to identify which claims are in a particular status location code Cre
32. DAYS 222111222B XXXXXX P B9996 131 0726XX 0726XX 0923XX 1001XX SMITH A 1600 00 1304 00 1015XX 37186 444333444A XXXXXX P B9996 131 0730XX 0730XX 0927XX 1001XX WHITE J 1200 00 1216 00 1015XX 37186 666777666A XXXXXX P B9996 131 0810XX 0810XX 1008XX 1009XX JONES S 1800 00 1296 00 1023XX 37186 PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD c You can view individual claims by typing S in the SEL field next to the HICN of the individual claim law Map 1741 will display a maximum of 5 claims at any given time To see if there are additional claims press your F6 key to scroll forward Claim Status Inquiry Examples When you are inquiring about specific information whether it is specific beneficiary claims history information or specific status location code information you can tailor your search using one or more additional fields In addition to entering your NPI a HICN and S LOC you can enter data in the TOB type of bill FROM DATE and TO DATE fields circled and bolded below to further narrow your search Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NQUIRY WENU CHAPTER 3 MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI HIC PRO DER OC OPERATOR ID DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAS
33. EASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD If no claims appear after you press Enter check the HICN to ensure it is entered correctly You may need to verify whether the HICN was changed by accessing the beneficiary s eligibility information When the information appears you will see a two line summary of each claim s information To see more detail you can select a specific claim which will provide six pages of complete claim TT information Additional pages will display when a claim has been selected for Medical Review and requires additional information be submitted via the ADR process d To select a claim press your Tab key until your cursor moves under the SEL field and is to the left of the HICN of the claim detail you want to view Type S in the SEL field and press Enter You can only select one claim at a time MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI 1234567890 HIC 123456789A PROVIDER S LOC TOB OPERATOR ID XXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS 5 23456789A XXXXXX P B9997 131 0817XX 0817XX 0817XX 0902XX SMITH J 684 00 0908XX 1030XX 37185 PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD Note in the above e
34. ERVICES Y A MA02 IF YOU DO NOT AGREE WITH THIS DETERMINATION YOU HAVE THE R A MA04 110407 SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTITY A MAOS 101603 INCORRECT ADMISSION DATE PATIENT STATUS OR TYPE OF BILL EN A MA06 080104 INCORRECT BEGINNING AND OR ENDING DATE S ON CLAIM A MAO7 110407 THE CLAIM INFORMATION HAS ALSO BEEN FORWARDED TO MEDICAID F A MAO8 110407 YOU SHOULD ALSO SEND THIS CLAIM TO THE PATIENT S OTHER INSU A MA09 110407 CLAIM SUBMITTED AS UNASSIGNED BUT PROCESSED AS ASSIGNED YO A MA10 110407 THE PATIENT S PAYMENT WAS IN EXCESS OF THE AMOUNT OWED YOU A MA100 110407 DID NOT COMPLETE OR ENTER ACCURATELY THE DATE OF CURRENT IL A MA101 110407 DID NOT COMPLETE OR ENTER ACCURATELY THE DATES PATIENT WAS A MA102 080104 DID NOT COMPLETE OR ENTER ACCURATELY THE REFERRING ORDERING A MA103 110407 OUR RECORDS INDICATE THAT ONE OR MORE OF THE MEDICAL SERVIC A MA104 013104 DID NOT COMPLETE OR ENTER ACCURATELY THE DATE THE PATIENT W A MA105 060205 OUR RECORDS INDICATE THAT ONE OR MORE OF A NOT OTHERWISE CL PROCESS COMPLETED PLEASE CONTINUE PLEASE MAKE A SELECTION ENTER NEW KEY DATA PRESS PF 3 EXIT PF6 SCROLL FWD 5 Type S in the S field to view the entire narrative for the ANSI reason code and press Enter MAP1581 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ANSI STANDARD CODES SEL INQUIRY C201135E HH MM SS RECORD TYPE C ADJ REASONS G GROUPS R REMARKS A APPEALS STANDARD CODE
35. EVENUE CODES 010114 F 3 030X 010113 F 3 030X 010112 F 3 030X 010111 F 3 030X HCPC DESCRIPTION Parathormone parathyroid hormone level PROCESS COMPLETED PLEASE CONTINUE PLEASE ENTER DATA OR PRESS PF3 TO EXIT ap Use the following function keys to move around the screen F3 Exit return to the Inquiry Menu F11 Scroll right F5 Scroll up one page F10 Scroll left F6 Scroll down one page 4 Press F11 to move the screen to the right Map 1772 will display The type of data that displays will depend on the type of HCPCS code you enter Press F10 to move back to the left of Map 1771 Refer to the following for more information If the code is any other type of HCPCS code Map 1772 will display the 60 percent 62 percent rehabilitation and professional service rates Press F10 to move back to the right to Map 1771 Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL eee NQUIRY MENU MAP1772 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc HCPC RATES INQUIRY C201135E HH MM SS PAGE 02 CARRIER XXXXX OC XX HCPC 83704 EFF DT TRM DT 60 RATE 62 REDU NFACPE 010109 47 610 010108 44 080 45 550 010107 44 080 45 550 010106 44 080 45 550 HCPC DESCRIPTION LIPOPROTEIN BLOOD QUANTITATION OF LIPOPROTEIN PARTICLE NUMBERS AND LIPOPROTEIN PARTICLE SUBCLASSES EG BY NUCLEAR MAGNETIC RESONANCE SPECTROSCO
36. EXIT OSC Repository Inquiry Option 1A This option is used to retain the history of all Occurrence Span Codes OSCs billed by Long Term Care Hospital LTCH Inpatient Psychiatric Facility IPF and Inpatient Rehabilitation Facility IRF providers 1 From the Inquiry Menu type 7A in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF LO ZIP CODE FILE 19 DRG PRICER GROUPER 11 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY L2 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 L5 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES 17 ENTER MENU SELECTION 1A PLEASE ENTER DATA OR PRESS PF3 TO EXIT Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NQUIRY MENU Claim Count Summary Option 56 This option provides a summary of all of your facility s billing transactions that are currently processing within FISS by status location and type of bill This option will assist you in getting a quick picture of where all of your processing claims are located in FISS CGS recommends that you check option 56 when you first sign into FISS for the day This screen is only updated in the evening Monday through Friday By reviewing option 56 you can easily id
37. JIN UR MIEN C DIRECT DATA ENTRY DDE MANUAL CHARIER gt Q C G gt d August 22 2014 Create A CELERIAN GROUP COMPANY 2014 Copyright CGS Administrators LLC NQUIRY MENU CHAPTER 3 Table of Contents Inguiry Menu Options 4 Access the Inguiry Menu 4 Beneficiary CWF Option 10 5 Field Descriptions for Option 10 Beneficiary CWF Screen 8 Map 1751 Page 1 Screen Example 8 DRG Pricer Grouper Option 11 8 Claims Option 12 9 Checking the Status of Your Claims Beneficiary Claim History 10 Claim Example 12 Claim Status Inquiry Examples 13 Accessing Additional Development Request ADR Information 15 Identifying Claims Selected for ADR 15 Example FISS Page 07 17 Example FISS Page 08 17 Key ADR Information 19 Field Descriptions for Option 12 Claims 20 Map 1741 Screen Example 20 Field Descriptions for Map 171A 22 Map 171A Screen Example 22 Field Descriptions for Map 171D 25 Map 171D Screen Example 25 Archived Claims 29 Revenue Codes Option 13 30 Field Descriptions for Option 13 Revenue Codes 31 HCPC Codes Option 14 32 Field Descriptions for Option 14 HCPC Codes 34 DX Proc Codes ICD 9 Option 15 36 Field Descriptions for Option 15 DX PROC Codes ICD 9 37 Adjustment Reason Codes Option 16 37 Field Descriptions for Option 16 Adjustment Reason Codes 39 Reason Codes Option 17 40 Field Descriptions for Option 17 Reason Codes 42 Zip Code File Option 19 45 Gae YA CoS
38. Key ADR Information that follows these instructions This information will help you avoid claim denials Identifying Claims Selected for ADR You can easily see if claims are selected for ADR by accessing the Inquiry Menu and selecting option 12 Claim Summary Claims selected for ADR will appear in status location S B6001 ma CGS recommends that you check the ADR status location S B6001 at least once per week to help ensure timely responses 1 On Map 1741 type your facilitys NPI number in the NPI field To move the cursor to the NPI field hold down the Shift key and press the Tab key 2 Tab to the S LOC field and type S B6001 Press Enter If there are claims in the S B6001 status location they will appear after you press Enter Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Paes NQUIRY MENU MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI NNNNNNNNNN HIC PROVIDER TOB OPERATOR ID FROM DATE TO DA DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS 3 To identify the additional information being requested for each claim you must select the claim by typing an S in the SEL field next to the HICN of the claim Press Enter You can only select one claim at a time MAP1741 CGS J1
39. LE 19 DRG PRICER GROUPER 11 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES I7 ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT You may also access this screen by typing 1B in the SC field if and pressing Enter if you are in an inquiry or claim entry screen 2 The ICD 10 CM Code Inquiry screen Map 1C31 appears MAP1C31 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc ICD 10 CODE INQUIRY C201135E HH MM SS DIAG PROC STARTING ICD 10 CODE D P ICD 10 CODE DESCRIPTION EFFECTIVE TERM DATE PLEASE ENTER DATA OR PRESS PF3 TO EXIT Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MAN UAL
40. LEFT PF11 RIGHT In the screen example above the fields that appear in bold type are fields that you will want to review to identify Pricer downcoding upcoding information REV This field identifies the revenue code line that displays The detail includes the revenue code HCPC code service date SERV DATE total units TOT UNT and covered units COV UNT APC CD This field displays the APC code OCE FLAGS This field will display a X indicating that the line item paid under OPPS Separate APC payment To view Pricer information for another line item revenue code use your F5 and F6 keys to scroll up or down until you see the appropriate line item displayed in the REV field e Press F2 or F10 twice to return to Map 1712 Press F3 to return to the Claim Summary Inquiry screen Map 1741 Map 171A field descriptions can be found later in this chapter directly following the field descriptions for Map 1741 Field Descriptions for Option 12 Claims Map 1741 Screen Example MAP1741 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX sc CLAIM SUMMARY INQUIRY C201135E XX XX XX NPI HIC PROVIDER S LOC TOB OPERATOR ID FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD
41. LLE TN Q PATIENT CNTRL NBR XXXXXXX XXXXXXX DUE DATE 04 23 20XX MEDICAL REC NO DCN XXXXXXXXXXXXXXPAR HIC NNNNNNNNNA PATIENT NAME S Kn FROM DATE 02 01 20XX THRU DATE Q X MED ANALYST TOTAL CHARGES 1000 00 PRESS PF3 EXIT PF5 SCROL PF8 NEXT PF9 UPDT ma Press F6 to view the entire message Press F5 to scroll backward REPORT 001 MEDICARE PART A 15XXX PVDR NO XXXXXXXXXX DATE MM DD CCYY ADDITIONAL DEVELOPMENT REQUEST BILL TYPE 813 CASE ID 15004XXXXXXXXXXXXXXPAROPR ANYNAME HEALTH CENTER 1111 MAIN ST ANYTOWN IA 52001 1111 WILL BE DENIED LACK OF RESPONSE ONE WAY THE CONTRACTOR ACCEPTS SOLICITED DOCUMENTATION FROM PROVIDERS IS VIA ELECTRONIC SUBMISSION OF MEDICAL DOCUMENTATION ESMD MECHANISM FOR MORE INFORMATION ABOUT ESMD SEE WWW CMS GOV ESMD SOLICITED LETTERS CAN BE ANY ADR LETTERS AT THE CONTRACTORS DISCRETION AND NOT SOLEY FOR MEDICAL REVIEW YOU MAY FAX YOUR RESPONSE TO 515 471 7581 YOU MAY MAIL YOUR RESPONSE TO THE ATTENTION OF CGS J15 MAC J1i5 Part A PCC P O BOX 20200 NASHVILLE TN 37202 PATIENT CNTRL NBR XXXXXXX XXXXXXX DUE DATE 04 23 20XxX MEDICAL REC NO DCN XXXXXXXXXXXXXXPAR HIC NNNNNNNNNA PATIENT NAME FIRSTNAME LASTNAME FROM DATE 02 01 20XX THRU DATE 02 29 20XX OPR MED ANALYST TOTAL CHARGES 1000 00 ORIG REQ DT 03 09 20XX CLM RCPT DT 03 07 20XxX PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF8 NEXT PF9 UPDT 6 To determine what documentation is being reques
42. M DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS 123456789D XXXXXX XXX 0523XX 0523XX 0524XX 0603XX 3413 57 0617XX XXXXX 123456789D XXXXXX P 09998 XXX 0603XX 0603XX 0614XX 1305 00 0628XX XXXXX Revenue Codes Option 13 This option is helpful if you need to verify revenue codes that can be billed with specific bill types This screen also provides information to verify what additional information e g units HCPCS code must accompany the revenue code 1 From the Inquiry Menu type 13 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC HHH REGION ACPFA052 XX XX XX XXXXXX INQUIRY MENU C201135E XX XX XX BENEFICIARY CWF LO ZIP CODE FILE 19 DRG PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 L5 CHECK HISTORY FI ADJUSTMENT REASON CODES L6 DX PROC CODES ICD 10 1B REASON CODES L7 ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT m You may also access this screen by typing 13 in the SC field if you are in an inquiry or claim entry screen 2 The Revenue Code Table Inquiry screen Map 1761 appears MAP1761 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc REVENUE CODE TABLE INQUIRY C201135E HH MM SS REV CD EFF DT IND TERM DT NARR ALLOW HCPC UNITS RATE TOB EFF DT TRM DT EFF DT TRM
43. Medicare Secondary Payer Blood Deductibles MSP CASH DEDUCTIBLES Medicare Secondary Payer Cash Deductibles MSP COINSURANCE Medicare Secondary Payer Coinsurance Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL E MENU NQUIRY Map 171A Field Descriptions Fields prior to the start of the revenue code line item information first four rows of information are system generated from Page 01 of the claim ANSI ESRD RED PSYCH HBCF ANSI End Stage Renal Disease Reduction Psychiatric Coinsurance Hemophilia Blood Clotting Factor ANSI VALCD 05 OTHER ANSI Value Code 05 Other Identifies the 2 position ANSI group code and 3 position ANSI reason adjustment code The ANSI data for the value codes are reported on the Remittance Advice for the Value Code 05 Other amount MSP PAYER 1 Medicare Secondary Payer Payer 1 Identifies the amount entered by the provider if available or apportioned by FISS as payment from the primary payer FISS based on the amount used in payment calculation and the value code for the primary payer apportions this amount MSP PAYER 2 Medicare Secondary Payer Payer 2 Identifies the amount entered by the provider if available or apportioned by FISS as payment from the secondary payer FISS based on the amount used in payment calculation and the value code for the secondary payer apportions this amount OTAF Oblig
44. O STORE THE CLAIM OTHER PROVIDERS RETURN TO THE INTERMEDIARY PROCESS COMPLETED PLEASE CONTINUE PRESS PF3 EXIT PF6 SCROLL FWD PF8 NEXT g NOTE Please note that you may need to press F6 to scroll forward to see all of the reason code narrative 4 To see the ANSI reason code that corresponds to the FISS reason code press your F8 key The ANSI Related Reason Codes Inquiry screen Map 1882 appears Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL CHAPTER 3 INQUIRY MENU MAP1882 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc ANSI RELATED REASON CODES INQUIRY C201135E HH MM SS MNT XXXXXX MMDDYY REASON CODE 38107 PIMR ACTIVITY CODE DENIAL CODE MR INDICATOR PCA INDICATOR LMRP NCD ID ANSI CODES ADJ REASONS LOY GROUPS CO REMARKS M1 APPEALS A MA02 APPEALS B MA01 CATEGORY EMC Pl HC Pl STATUS 5 EMC 0020 HC 0020 PRESS PF3 EXIT PF7 PREV PAGE Field Descriptions for Option 17 Reason Codes Map 1881 Field Descriptions MNT Identifies the last operator who created or revised this screen and the date For intermediary use only PLAN IND Plan indicator For intermediary use only REAS CODE Reason code The reason code identifies a specific condition assigned to the claims during processing The following identifies the meaning of the first digit of the reason code First Digit of Mea
45. ON ENTER NEW KEY DATA PRESS PF3 EXIT PF6 SCROLL FWD e When you view option 56 pay particular attention to whether you have claims in status locations S B6001 and T B9997 These two status locations require that you take action Claims in S B6001 require that you submit the information being requested via the ADR Select option 12 Claims from the Inquiry Menu to determine which claims were selected and what documentation you need to submit to respond to the ADR For information about identifying and responding to ADRs refer to the Claims Option 12 information found earlier in this chapter Claims in the RTP status location T B9997 require that you make the necessary corrections to the claims Select 03 Claims Correction from the Main Menu to correct claims e The TOTAL PAYMENT column identifies the payment amount for those claims that have been approved for payment on the payment floor and are in status location P B9996 Option 56 updates when the system cycle runs each night Monday through Friday Therefore if option 56 indicates that you have two claims to correct and you immediately correct both claims option 56 will continue to indicate that you have two claims to correct until the screen updates during the nightly cycle Please note that nightly cycles do not typically run on Federal holidays e After suppressing the view of a claim it will no longer display in the RTP file however when
46. OSURE ENTER PROCESS Claims Option 12 You will use this option often because it allows access to a variety of claim processing information The following provides instructions on how to e Check the status of your billing transactions beneficiary claim history Check for Additional Development Requests ADRs e View line item denial information 1 From the Inquiry Menu type 72 in the Enter Menu Selection field and press Enter MAP1702 MM DD YY XXXXXX BEN DRG HCP DX ADJ ENTER MENU SELECTION CGS J15 MAC Part A REGION ACPFA052 INQUIRY MENU C20112WS HH MM SS EFICIARY CWF LO ZIP CODE FILE 19 PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 C CODES 14 ANSI REASON CODES 68 PROC CODES ICD 9 15 CHECK HISTORY FI USTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES L7 PLEASE ENTER DATA OR PRESS PF3 TO EXIT Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL INGU RY MENU The Claim Summary Inguiry screen Map 1741 appears MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI HIC PROVIDER S LOC TOB OPERATOR ID XXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT
47. RY C201135E HH MM SS MNT PLAN REAS NARR EFF MSN EFF TERM EMC HC PRO PP CC IND CODE TYPE DATE REAS DATE DATE ST LOC ST LOC LOC IND 1 E TPTP A B NPCD A B HD CPY A B NB ADR CAL DY C L SRS SREP Stas SS SERS E arka en SS STS kaka see NARRATIVES ss 2 s23Se3 SSeS ee SSS saa ST aaa ya aan a aka pa ka aan PLEASE ENTER DATE OR PRESS PF3 TO EXIT 3 Enter the reason code in the REAS CODE field and press Enter Reason codes are found at the bottom left corner of the FISS claim pages Whenever m a reason code appears on your claim the easiest way to access it is to press your F1 key Note that having a reason code present on your claim does not mean that it needs correction For example even when a claim is in a P paid status FISS still assigns a reason code to the claim Refer to the Chapter 5 of this guide to further understand when you need to correct a claim MAP1881 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc REASON CODES INQUIRY C201135E HH MM SS MNT XXXXXX MMDDYY PLAN REAS NARR EFF MSN EFF TERM EMC HC PRO PP CC IND CODE TYPE DATE REAS DATE DATE ST LOC ST LOC LOC IND 1 32402 E 052394 T T TPTP A B NPCD A B HD CPY A B NB ADR CAL DY C E G NARRATIVE HCPCS CODE REPORTED ON THIS CLAIM HAS NOT BEEN BILLED WITH A VALID REVENUE CODE FOR THE DATES OF SERVICE VERIFY BILLING AND IF APPROPRIATE CORRECT ONLINE PROVIDERS PRESS PF9 T
48. T NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS 1 Type of Bill TOB You can narrow the search of a beneficiary s claims by entering a type of bill TOB For example to review outpatient final claims submitted for a beneficiary type your facility s NPI in the NPI field the beneficiary s HICN in the HIC field and the home health type of bill code 131 in the TOB field MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI NNNNNNNNNN PROVIDER S LOC OPERATOR ID FROM DATE TO DATE DD SOR MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS To search for a beneficiary s claims for specific dates of service and specific type of bill type your facility s NPI the beneficiary s HICN the type of bill and the from and to dates Entering a status code or status location will further narrow your search See example below MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI NNNNNNNNNN PROVIDER 10 Tos 131 OPERATOR 1D FROM DATE 080113 TO DATE 093013 DD OR MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS It is a good idea to refresh your screen between different search
49. T1234567 indicate that your facility Field Descriptions for Option FI Check History Map 1582 Field Descriptions PROV Your Provider Transaction Access Number PTAN When entered without the NPI only 2008 check history will display NPI Your facility s National Provider Identifier NPI CHECK The check number or EFT transaction number associated with the issued payment DATE The date of the issued payment YYMMDD format AMOUNT The dollar amount of the payment issued This amount can reflect all payments from Medicare e g claims cost report settlements etc Dx Proc Codes ICD 10 Option 1B This option is helpful if you need to confirm the validity of ICD 10 CM diagnosis or ICD 10 PCS procedure codes The compliance date for implementation of the ICD 10 CM coding system is October 1 2015 As a result the information below is limited and shows only how this option is accessed For more information about ICD 10 implementation refer to the Centers for Medicare amp Medicaid Services CMS at https www cms gov Medicare Coding ICD10 index html Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL KE NQ YIRY MENU 1 From the Inquiry Menu type 7B in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF LO ZIP CODE FI
50. XXXXX SC CLAIM IMMARY INQUIRY C20112WS HH MM SS PROVIDER S LOC TOB OPERATOR D XXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Gao NQUIRY MENU a Only the billing transactions that your facility submitted under the beneficiary s HICN and NPI will display You will not have access to claims submitted by other providers c After you press Enter FISS will search and display all claims submitted by your facility for that specific beneficiary A maximum of 5 claims will display If 5 claims display press your F6 key to scroll forward to see if there are additional claims MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI 1234567890 HIC 123456789A PROVIDER S LOC TOB OPERATOR ID XXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS 1234567890 XXXXXX P B9997 131 0817XX 0817XX 0817XxX 0902XX SMITH J 684 00 0908XX 1030XX 37185 123456789A XXXXXX P B9997 131 0817XX 0817XX 1015XX 1019XX SMITH J 1089 00 1140 00 1030XX 37185 PL
51. alculated by the Pricer Grouper software programs within FISS Because this information is typically used only by hospitals and this guide provides information relevant only to home health and hospice agencies the information below is limited and shows only how this option is accessed 1 From the Inquiry Menu type 77 in the Enter Menu Selection field and press Enter You may also access this screen by typing 77 in the SC field if you are in an inquiry or claim entry screen Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL KET NQUIRY MENU 2 The DRG PPS Inquiry screen Map 1781 appears MAP1781 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC DRG PPS INQUIRY C20112WS HH MM SS DIAGNOSES 1 2 3 4 5 6 7 8 9 POA PROCEDURES 1 2 3 4 5 6 7 8 9 NPI SEX G 1 DISCHARGE STATUS DT PROV REVIEW CODE TOTAL CHARGES DOB OR AGE APPROVED LOS COV DAYS LTR DAYS PAT LIAB RETURNED FROM GROUPER GROUPER VERSION D R G MAJOR DIAG CAT RETURN CODE PROC CD USED DIAG CD USED SEC DIAG USED RETURNED FROM PRICER PRICER VERSION RTN CD WAGE INDEX OUTLIER DAYS AVG LENGTH OF STAY OUTLIER DAYS THRESHOLD OUTLIER COST THRES INDIRECT TEACHING ADJ TOTAL BLENDED PAYMENT HOSPITAL SPECIFIC PORTION FEDERAL SPECIFIC PORTION DISP SHARE HOSPITAL AMT PASS THRU PER DISCHARGE OUTLIER PORTION PTPD TEP STANDARD DAYS USED LTR DAYS USED PROV REIMB PLEASE ENTER DATA PF3 EXIT PF6 FWD PF8 COST DISCL
52. and entering the beneficiary s HICN in the HIC field Then tab to the S LOC field and enter P 09998 or R 09998 Press Enter Archived claims do not display the beneficiary s name or provider reimbursement PROV REIMB amount and if selected type an S in the SEL field all claim pages appear blank The message ADJUSTMENT CLAIM IS PRESENTLY OFFLINE PF10 TO RETRIEVE will display Although the claim data is archived you are able to retrieve an archived claim to inquire into how it was submitted and processed For additional information on how to retrieve an archived claim refer to Chapter 5 of this guide Please note that because Section 6404 of the Patient Protection and Affordable Care Act PPACA amended the timely filing requirements to one calendar year after the date of service adjustments or claim cancellations cannot be done after a claim has been archived unless a valid exception to timely filing has been met See the Medicare Timely Filing Guidelines http www cgsmedicare com Articles COPE18411 html Web page for more information Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Pa NQUIRY MENU MAP1741 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX SC CLAIM SUMMARY INQUIRY C201135E XX XX XX NPI XXXXXXXXXX HIC NNNNNNNNND PROVIDER S LOC P 09998 TOB OPERATOR ID FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FR
53. are U upcoding D downcoding no downcoding HCPC Healthcare Common Procedure Coding System Indicates 5 position HCPCS associated with the revenue code MODIFIERS Healthcare Common Procedure Coding System Modifier SERV DATE Service date Line item date of service associated with the revenue code COV UNT Covered units Reflects the number of covered visits associated with the revenue code COV CHRG Covered charges Represents the covered charges associated with the revenue code ADR REASON CODES Additional Development Request ADR reason codes used when additional information has been requested FMR REASON CODES Focused Medical Review Suspense Codes Identifies the medical review suspense codes when a claim is edited based on the medical policy parameter file ODC REASON CODES Original Denial Reason Code Identifies the original denial reason codes ORIG ORIG REV CODE Original HCPCS or HIPPS code or modifiers billed Original revenue code billed MR Complex Manual Medical Review Indicator Identifies if all services on the claim received complex manual medical review Valid values are 7 services did not receive manual medical review Y medical records received and services received complex manual medical review N medical records were not received and services received routine manual medical review Created August 22 2014 2
54. ated August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Sete NQUIRY MENU If you want to know specifically which six claims are in P B9996 press F3 to exit option 56 Select 12 Claims from the Inquiry Menu and press Enter Type your facility s NPI number in the NPI field then tab to the S LOC field and enter P B9996 Press Enter All the claims for your facility that are in status location P B9996 will appear See below Remember that you may need to press F6 to scroll forward to see all claims MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc CLAIM SUMMARY INQUIRY C201135E HH MM SS NPI XXXXXXXXXX HIC PROVIDER S LOC P B9996 TOB OPERATOR ID XXXXXXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS NNNNNNNNNA XXXXXX P B9996 131 0805XX 0801XX 0831XX 1006XX LASTNAME A 1203 00 1008 00 1103XX 37186 NNNNNNNNNB XXXXXX P B9996 131 0807XX 0801XX 0831XxX 1006XX LASTNAME B 1500 00 896 00 1103XX 37186 NNNNNNNNND XXXXXX P B9996 131 1101XX 1101xXx 1130XX 0202XX LASTNAME C 1653 00 1400 00 0302XX 37186 NNNNNNNNNA XXXXXX P B9996 131 1001XX 1001XX 1031XX 0202XX LASTNAME D 795 00 392 00 0301XX 37186 NNNNNNNNNA XXXXXX P B9996 131 1001XX 1001XX 1028XX 0212XX LASTNAME E 1512 00 1120 00 0311XX 37186 PROCESS COMPLETED PLEASE CONTINUE PLEASE MAKE A SELECTI
55. ated to Accept Payment in Full Identifies the line item apportioned amount entered by the provider if applicable or apportioned amount calculated by the MSPPAY module of the obligated to accept as payment in full when value code 44 is present MSP DENIAL IND Medicare Secondary Payer Denial Indicator Identifies to the MSPPAY module that an insurer primary to Medicare has denied this line item The valid values are not denied D denied OCE FLAGS Flag 1 Service Indicator valid values are B Non allowed item or service for OPPS M Medical Review changes a HIPPS code P Pricer upcode downcode The Pricer program in FISS changes the HIPPS code to early or late based on the beneficiary s adjacent episode history posted to the Common Working File CWF and or the claim contains more or less therapy revenue codes than indicated by the HIPPS code submitted Flag 2 Payment Indicator Flag 3 Discounting Formula Number Flag 4 Line Item Denial or Rejection Flag Flag 5 Packing Flag Flag 6 Payment Adjustment Flag Flag 7 Payment Method Flag Flag 8 Line Item Action Flag Flag 9 Composite Adjustment PAY HCPC APC CD Payment Ambulatory Patient Classification Code or HCPC Ambulatory Patient Classification Code MSP PAYER 1 ID Medicare Secondary Payer Payer 1 ID Displays 1 position alphanumeric code identifying the specific payer If Medicare is primary this field will
56. display g NOTE If you enter only your facility s PTAN in the PROV field only check history from 2008 oeoa Caah Cos Apan te DIRECT DATA ENTRY ODE MANUAL E A CHARTER 3 INQUIRY MENU MAP1B01 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc CHECK HISTORY C201135E HH MM SS PROV NPI NNNNNNNNNN CHECK DATE AMOUNT PLEASE ENTER DATA OR PRESS PF3 TO EXIT 4 Press Enter to see check history for the three most recent reimbursements that were distributed to your facility either by check or Electronic Funds Transfer EFT The PTAN will display in the PROV field after you type the NPI in the NPI field and press Enter MAP1BO01 CGS J15 MAC Part A REGION ACPFA052 03 23 12 XXXXXX SC CHECK HISTORY C201135E HH MM SS PROV XXXXXX NPI NNNNNNNNNN CHECK DATE AMOUNT EFT2223333 YY1024 916 56 EFT1112222 YYIO 10 941 16 EFTO001111 yyY1018 12 468 66 PROCESS COMPLETED PLEASE CONTINUE PLEASE ENTER DATA OR PRESS PF3 TO EXI Please note that one day is added to the paid date that appears in the Check History screen m The example above of the Check History screen was viewed on 10 23 The RA ERA for the _ paid amount 916 56 will be dated 10 23 However in FISS for each individual claim record that appears on that RA ERA the paid date will display as 1023 receives its reimbursement via Electronic Funds Transfer EFT ma Check numbers that start with the letters EFT e g EF
57. e HCPCS code became required for this revenue code MMDDYY format TRM DT HCPCS termination date The date the HCPCS code was no longer required for this revenue code MMDDYY format UNITS Units required This field indicates whether units must be entered for this revenue code Values are Y Yes N No EFF DT Unit s effective date The beginning date units became required for this revenue code MMDDYY format TRM DT Unit s termination date The date units were no longer required for this revenue code MMDDYY format RATE Rate This field indicates whether a rate must be entered for this revenue code Values are Y Yes N No Note This field is currently not functional and will always show N EFF DT Rate s effective date The beginning date for the requirement to enter a rate for this revenue code MMDDYY format TRM DT Rate s termination date The end date for the requirement to enter a rate for this revenue code MMDDYY format Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL ences HCPC Codes Option 14 This option is helpful if you need to inquire about Healthcare Common Procedure Coding System HCPCS code reimbursement or verify which revenue codes are allowable with HCPCS codes 1 From the Inquiry Menu type 14 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM
58. e revenue code line item information first four rows of information are system generated from Page 01 of the claim UNTITLED Claim line item number 1 450 REV HCPC Revenue code identifies the revenue code for specific billed service Healthcare Common Procedure Code identifies the HCPC code that further defines the revenue code MODIFIERS Healthcare Common Procedure Code System Modifier SERV DATE Date service was provided SERV RATE TOT UNT Per unit rate for revenue code line item service Total units COV UNT Covered units TOT CHRG Total charges per revenue code COV CHRG Covered charges per revenue code ANES CF Anesthesia Conversion Factor ANES BV Anesthesia Base Units Value PC TC IND Professional Component Technical Component Not applicable to home health and hospice providers HCPC TYPE PAT BLOOD DEDUCTIBLES An M indicator will display when the HCPCS associated with the revenue line originated from the Medicare physician fee schedule Patient Blood Deductibles PAT CASH DEDUCTIBLES Patient Cash Deductibles REDUCED COINSURANCE Reduced Coinsurance ESRD RED PSYCH HBCF ESRD Reduction Amount Psychiatric Reduction Amount Hemophilia Blood Clotting Factor Amount VALCD 05 OTHER Value Code 05 Other Identifies whether value code 05 is present on the claim MSP BLOOD DEDUCTIBLES
59. ed by CGS Valid values are D denied line item for the reason code R rejected the line item for the reason code _ processed claim with no override action MED TEC Medical Technical Denial Indicator Identifies the appropriate Medical Technical Denial indicator used when performing the medical review denial of a line item The valid values are M medical denial and waiver was applied S medical denial and waiver was not applied T technical denial and waiver was applied U technical denial and waiver was not applied ANSI ADJ ANSI Adjustment Reason Code Identifies the ANSI adjustment reason code associated with the denial reason for each line item ANSI GRP ANSI Group Code Contains the ANSI group code associated with the denial reason for each line item ANSI REMARKS ANSI Remarks Code Contains the ANSI remarks codes associated with the denial reason for each line item TOTAL Contains the sum of all revenue code noncovered units LINE ITEM REASON CODES Identifies the reason code that is assigned for suspending the line item Archived Claims FISS archives claim data on processed claims after 18 months from the date the claim is processed Archived claims can be identified by status location P 09998 or R 09998 the letter O as in offline and not a 0 zero These claims can be accessed by selecting 12 Claims from the Inquiry Menu typing your NPI in the NPI field
60. ed to verify Medicare eligibility because it may not be as current as the CWF information that you access via ELGA For information about accessing ELGA refer to Chapter 2 of this guide You may also access this screen by typing 10 in the SC field if you are in an inquiry or claim entry screen Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL eee INGU RY MENU The Eligibility Detail Inguiry screen Map 1751 appears MAP1751 MM DD YY XXXXXX Sc CGS J15 MAC Part A REGION ELIGIBILITY DETAIL INQUIRY HIC CURR XREF HIC TRANSFER HIC C IND LTR DAYS LN FN MI SEX DOB DOD ADDRESS 1 2 3 4 5 6 ZIP CURRENT ENTITLEMENT PART A EFF DT TERM DT PART B EFF DT CURRENT FRST BILL DT SNF FULL DAYS BENEFIT PERIOD DATA LST BILL DT HSP FULL DAYS SNF PART DAYS INP DED REMAIN PSYCHIATRIC PSY DAYS REMAIN PRE PHY DAYS USED PSY DIS DT PLEASE ENTER DATA HIC LN FN SEX AND DOB PRESS PF3 EXIT PF8 NEXT PAGE PREV XREF HIC ACPFA052 C20112WS HH MM SS TERM DT HSP PART DAYS BLD DED PNTS INTRM DT IND 3 As indicated at the bottom of the Map 1751 you must have the following five pieces of information about the beneficiary to access information HICN Health Insurance Claim Number also called their Medicare number Last Name First Name Gender Date of Birth MMDDCCYY format You can use the following function keys to move around the sc
61. entify if there are claims On the payment floor P B9996 which means your claim has been approved for payment In an Additional Development Request ADR status S B6001 which means that CGS has requested that you submit additional information or Ina Return to Provider RTP status T B9997 which means that the claim needs to be corrected by your facility 1 From the Inquiry Menu type 56 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF 10 ZIP CODE FILE 19 DRG PRICER GROUPER 1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES 17 ENTER MENU SELECTION 56 PLEASE ENTER DATA OR PRESS PF3 TO EXIT You may also access this screen by typing 56 in the SC field if you are in an inquiry or claim m entry screen 2 The Claim Summary Totals Inquiry screen Map 1371 appears MAP1371 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX Sc CLAIM SUMMARY TOTALS INQUIRY C201135E HH MM SS PROVIDER S LOC CAT NPI S LOC CAT CLAIM COUNT TOTAL CHARGES TOTAL PAYMENT PLEASE ENTER DATA OR PRESS PF3 TO EXIT PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD 3 To obtain the summary of billing
62. es Do this by pressing F3 to exit option 12 Then type 72 in the Enter Menu Selection field and press Enter 2 From To Date If the beneficiary has an extensive claim history you can narrow your search by adding from and to dates These dates reflect the from and to dates of service billed on the claim You may search by only using a from date or both a from and to date The to date can only be used if a from date is also entered For example to find claims with dates of service between August 1 2013 to September 30 2013 for a particular beneficiary type your facility s NPI in the NPI field the HICN in the HIC field and type 080173 in the FROM DATE field and 093013 in the TO DATE field and press Enter ma The top of the next page is an example of how this would appear before pressing Enter Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL once JIRY MENU MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI NNNNNNNNNN HIC NNNNNNNNNA PROVIDER Q TOB OPERATOR ID FROM DATE 080113 TO DATE 093013 DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS You may also use the FROM DATE field when searching for claims in a specific status location ma The exam
63. fies the amount for which the individual receiving services is responsible The amount is calculated as follows If Payer 1 indicator is C or Z the amount equals cash deductible coinsurance blood deductible If Payer 1 indicator is not C or Z the amount equals MSP blood MSP cash deductible MSP coinsurance PAT PAID Patient paid Identifies the line item patient paid amount calculated by the system This amount is the lower of patient reimbursement patient responsibility or the remaining patient paid after the preceding lines have reduced the amount entered on Page 03 of the claim REDUCT AMT Reduction amount A 10 percent reduction in conjunction with Group Code CO Not applicable to home health and hospice providers ANSI PROV REIMB ANSI Group Code and the Claim Adjustment Reason Codes related to the reduction amount Not applicable to home health and hospice providers Provider Reimbursement Identifies the system generated calculated line amount to be paid to the provider LABOR Identifies the labor amount of the payment as calculated by Pricer NON LABOR Identifies the non labor amount of the payment as calculated by Pricer MED REIMB Medicare Reimbursement Identifies the total Medicare reimbursement for the line item which is the sum of the patient reimbursement and the provider reimbursement CONTR ADJUSTMENT Contractor Adjustment Identifies the total contractua
64. ical review and reconsideration only Valid values are A pay per waiver full technical B pay per waiver full medical C provider liability full medical subject to waiver provision D beneficiary liability full subject to waiver provision E pay claim line full F pay claim partial claim must be updated to reflect liability G provider liability full technical subject to waiver provision H full partial denial with multiple liabilities claim must be updated to reflect liability I full provider liability medical not subject to waiver provision J full provider liability technical not subject to waiver provision K full beneficiary liability not subject to waiver provision L full provider liability code changed to reflect actual service M pay per waiver line or partial line N provider liability line or partial line Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL EA CHAPTER 3 INQUIRY MENU Map 171D Field Descriptions USER ACT CODE continued O beneficiary liability line or partial line P open biopsy changed to closed biopsy Q release with no medical review performed R CWF denied but medical review was performed Z force claim to be re edited by medical policy 5 set systematically from the reason code file to identify claims for which special
65. identifies the EMC category of the claim returned on a 277 claim status response HC CATEGORY Hard copy claim category code This field provides the ANSI code that identifies the hard copy category of the claim returned on a 277 claim status response EMC STATUS Electronic media claim status code This field provides the ANSI code that identifies the EMC status of the claim returned on a 277 claim status response HC STATUS Hard copy claim status code This field provides the ANSI code that identifies the hard copy status of the claim returned on a 277 claim status response Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Ear NQUIRY MENU Zip Code File Option 19 This option is applicable to ambulance providers It provides the geographic area definitions rural urban and super rural by zip code and by state 1 From the Inquiry Menu type 79 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF LO ZIP CODE FILE 19 DRG PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES L7 ENTER MENU SELECTION 19 PLEASE ENTER DATA OR PRESS PF3 TO
66. indicate that additional documentation is required to support the signatures The Remarks field on FISS Page 04 will specify the documentation being requested The additional signature documentation must be sent to CGS within 15 days of the request You may choose to submit documentation electronically See the esMD http www cgsmedicare com parta pubs news 2012 0312 288 html article for more information about electronic submission of documentation Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL ER NQUIRY MENU MAP171A PAGE 02 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX SC INST CLAIM INQUIRY C201135E XX XX XX DCN XXXXXXXXXXXXXXXX HIC NNNNNNNNNA RECEIPT DATE 1104XX TOB 131 STATUS P LOCATION B9997 TRAN DT XXXXXX STMT COV DT 0103XX TO 0302XX 4 SERV SERV HCPC MODIFIERS DATE RATE TOT UNT COV UNT TOT CHRG COV CHRG 1010 0103XX 60 60 q CF ANES BV PC TC IND HCPC TYPE DEDUCTIBLES COINSURANCE ESRD RED VALCD 05 BLOOD CASH WAGE ADJ REDUCED PSYCH HBCF OTHER PAT gt MSP gt ANSI gt PAY HCP MSP gt OUTLIER gt PAYER 1 PAYER 2 OTAF DENIA T FLAGS MSP gt INY 1 2 3 4 5 8 9 ID gt x REIMB RESP PAID REDU 7 PAT gt LABOR NON LABOR PROV gt 4369 91 MED gt 4369 91 PRICER PAY ASC ADJUSTMENT ANSI AMT RTC METHOD IDE NDC UPC GRP 3 CONTR 4369 91 CO 97 4369 91 37186 lt REASON CODES PRESS PF2 1712 PF3 EXIT PF5 UP PF6 DOWN PF7 PREV PF8 NEXT PF10
67. ional information about using FISS to submit adjustment and cancellation claims S201 cooman ccs Aahe Lie DIRECT DATA ENTRY ODE MANUAL Sas A NQUIRY MENU 1 From the Inquiry Menu type 76 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF 10 ZIP CODE FILE 19 DRG PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES L7 ENTER MENU SELECTION 16 PLEASE ENTER DATA OR PRESS PF3 TO EXIT You may also access this screen by typing 16 in the SC field if you are in an inquiry or claim ma entry screen 2 The Adjustment Reason Codes Inquiry screen Map 1821 appears MAP1821 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ADJUSTMENT REASON CODES INQUIRY C201135E HH MM SS SELECTION SCREEN MNT CLAIM TYPES I INPATIENT SNF O S OUTPA NT H HOME HEALTH CORF A ALL CLAIMS PLAN CODE REASON CODE S PC RC HC TYPE NARRATIVE 3 Press Enter to view a complete listing of adjustment reason codes on Map 1821 or type an adjustment reason code in the REASON CODE field and press Enter to display Map 1822 On Map 1821 press F6 to scroll forward through the list of ad
68. justment reason codes Press F5 to scroll backwards Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MAN UAL NQUIRY MENU MAP1821 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX sc ADJUSTMENT REASON CODES INQUIRY C201135E XX XX XX SELECTION SCREEN MNT XXXXXX MMDDYY CLAIM TYPES I INPATIENT SNF O OUTPATIENT H HOME HEALTH CORF A ALL CLAIMS PLAN CODE 1 REASON CODE PC RC HC TYPE NARRATIVE AA AA A This change is due to an automated adjustment 1 AC PI A AUDIT COMPLIANCE 1 AD AD I This overpayment is a result of a Quality Improvement Organizati 1 AH HF A ADJUSTMENTS TO DO FULL DENIAL ON PREVIOUSLY PAID CLAIM 1 AJ NN A HEARING REOPEN 1 AM AM I This overpayment is a result of a Quality Improvement Organizati 1 AP NW A HEARING PARTIAL 1 AR ARI This claim adjustment is due to a review that reversed the 1 AU AU A This overpayment is a result of a claim being processed with 1 AW AW I An admission denial adjustment has been processed however the 1 BB BB A This overpayment is a result of a same day transfer 1 BC BC A This overpayment is a result of the beneficiary file being 1 BL BL A This overpayment is a result of a claim being processed with 1 BP OR A PART B REVIEW PARTIAL 1 BR OO A PART B REVIEW REOPEN PROCESS COMPLETED PLEASE CONTINUE PLEASE MAKE A SELECTION ENTER NEW KEY DATA PRESS PF3 EXIT PF6 SCROLL FWD 4 Type Sin the S field t
69. l adjustment The calculation is submitted charge deductible wage adjusted coinsurance blood deductible value code 71 psychiatric reduction value code 05 other reimbursement amount Note For MSP claims the MSP deductible MSP blood deductible and MSP coinsurance is used in the above calculation in place of the deductible blood deductible and coinsurance amounts ANSI ANSI Group ANSI Adjustment Code Identifies the 2 position ANSI group code and 3 position ANSI reason adjustment code The ANSI data for the value codes are reported on the Remittance Advice PRICER AMT PRICER RTC Pricer Amount Identifies the total reimbursement received from Pricer Pricer Return Code Identifies the return code from the OPPS Pricer This is a 2 digit field The valid values are Home Health Prospective Payment System HH PPS Describes how the bill was paid 00 Final payment where no outlier applies 06 LUPA payment only 01 Final payment where outlier applies 07 Final Payment SCIC 02 Final payment where outlier applies but is not payable 08 Final Payment SCIC with Outlier due to limitation effective for claims when TO date is 09 Final Payment PEP on after January 1 2010 11 Final Payment PEP with Outlier 03 Initial percentage payment 0 12 Final Payment SCIC within PEP 04 Initial percentage payment 50 13 Final Payment SCIC within PEP 05 Initial percentage payment 60 with Outlier Describe
70. lean E Additional information was requested non PIP F Additional information was requested PIP Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL eee Map 1881 Field Descriptions CC IND continued MENU A reply was received from the Common Working File CWF providing a date of death which required development in order to process the claim non PIP A reply was received from CWF providing a date of death which required development in order to process the claim PIP A non definitive response was received from CWF requiring development non PIP A non definitive response was received from CWF requiring development PIP A definitive response was not received from CWF within 7 days delayed response non PIP A definitive response was not received from CWF within 7 days delayed response PIP The claim was manually set to non clean This will only occur in rare situations such as a claim requiring development external to the intermediary s operation non PIP The claim was manually set to non clean This will only occur in rare situations such as a claim requiring development external to the intermediary s operation PIP The claim is a sequential claim in which the prior claim was pending non PIP The claim is a sequential claim in which the prior claim was pending PIP TPTPA B For intermediary use only NPCDA B For intermediar
71. ma ccs Adohe DIRECT DATA ENTRY ODE MANUAL WENEH A NQUIRY MENU TERM DT The date that the ANSI code was deactivated MMDDYY NARRATIVE The description of the ANSI code Map 1582 Field Descriptions MNT Identifies the last operator who created or revised his screen and the date For intermediary use only RECORD TYPE The record type for the ANSI code STANDARD CODE The ANSI code within the above record type NARRATIVE The description of the ANSI code Check History Option FI This option identifies the three most recent Medicare payments issued to your facility 1 From the Inquiry Menu type FI in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF LO ZIP CODE FILE 19 DRG PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES L7 ENTER MENU SELECTION FI PLEASE ENTER DATA OR PRESS PF3 TO EXIT 2 The Check History screen Map 1B01 appears 3 To view current check history type your National Provider Identifier NPI in the NPI field or Provider Transaction Access Number PTAN in the PROV field and your NPI in the NPI field will
72. mbursement for the lab HCPCS When the MSI field equals a 5 this field will dispay 62 REDU or the reduced therapy fee amount REHAB Rehabilitation rate The rate used by the system to calculate reimbursement for the HCPCS code for rehabilitation services billed PROF Professional service rate The rate used by the system to calculate reimbursement for the HCPCS code for professional services NFACPE Non facility amount practice expense PE relative value units RVUs This field reflects the 20 percent reduction in non facility PE RVUs Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL En NQUIRY MENU DX Proc Codes ICD 9 Option 15 This option is helpful if you need to confirm the validity of diagnosis or procedure codes 1 From the Inquiry Menu type 15 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF 10 ZIP CODE FILE 19 DRG PRICER GROUPER 1I OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 IB REASON CODES I7 ENTER MENU SELECT ron a5 PLEASE ENTER DATA OR PRESS PF3 TO EXIT You may also access this screen by typing 15 in the SC field if y
73. n 17 The Reason Codes Inquiry screen provides an explanation description of the reason code on your claim You will use this option often to determine what actions are necessary to correct claims in the Return to Provider RTP file T B9997 Rather than selecting option 17 from the Inquiry Menu you will most likely access the reason codes by pressing F1 when you are in the Claims Entry or Claims Correction options in FISS 1 From the Inquiry Menu type 77 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C201135E HH MM SS BENEFICIARY CWF LO ZIP CODE FILE 19 DRG PRICER GROUPER Lil OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES ENTER MENU SELECTION 17 PLEASE ENTER DATA OR PRESS PF3 TO EXIT Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL Benen NQUIRY MENU You may also access this screen by typing 17 in the SC field if you are in an inquiry or claim entry screen or by pressing F1 while you are inquiring entering or correcting a claim 2 The Reason Codes Inquiry screen Map 1881 appears MAP1881 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC REASON CODES INQUI
74. ncluded in the PCA transfer files LMRP NCD ID Local medical review policy LMRP currently known as local coverage determination LCD and or national coverage determination NCD identification number The LMRP NCD ID number that are assigned to the FMR reason code for reporting on the Medicare Summary Notice Intermediary CMS defined ADJ REASONS Adjustment reasons This field provides the American National Standards Institute ANSI code that explains why an adjustment is being processed GROUPS Groups This field provides the ANSI code indicating the financial responsibility for the amount of the adjustment or identifies a postinitial adjudication adjustment in the X12 835 case segment The five group codes are PR Patient responsibility CO Contractual obligations OA Other adjustment CR Correction to or reversal of a prior decision 96 Noncovered charges REMARKS Remarks This field provides the ANSI code that identifies the reason for non payment This is a five position alphanumeric field with four occurrences APPEALS A Appeals A This field provides the ANSI code indicating the appeal rights related to the initial Part A determination APPEALS B Appeals B This field provides the ANSI code indicating the appeal rights related to the initial Part B determination Not applicable to hospice EMC CATEGORY Electronic media claim category code This field provides the ANSI code that
75. ning Example Reason Code Consistency 11801 missing invalid point of origin previously known as source Edits of admission FISS 37402 claims not submitted sequentially 38107 system cannot match final claim to processed RAP Medical Review 56900 no response to additional development request NARR TYPE Narrative type An E indicates the narrative is for external users EFF DATE Effective date The effective date of the reason code MSN REAS Medicare Summary Notice Reason If a denial is made on the claim the denial reason code in this field generates the narrative for the Notes section of the Medicare Summary Notice MSN EFF DATE Effective Date The effective date for the alternate reason TERM DATE Termination Date The termination date for the alternate reason EMC ST LOC Electronic media claims status and location The status and location set up for automated claims that encounter the reason code If this field is blank the HC PRO ST LOC field will apply HC PRO ST LOC Hardcopy Quality Improvement Organization QIO Status Location The status and location set up for hardcopy or QIO claims which encounter the reason code PRIEOE Post pay location This field identifies the post pay location for postpay development activities CC IND Clean claim indicator This field instructs the system whether to pay interest Values are A PIP other B PIP clean C Non PIP other D Non PIP c
76. nus payment 2 Professional component only pay the HPSA bonus 3 Technical component only do not pay the HPSA bonus 4 Global test only Professional component of this service qualifies for the HPSA bonus payment 5 Incident codes do not pay the HPSA bonus 6 Laboratory physician interpretation codes pay the HPSA bonus 7 Physical therapy service do not pay the HPSA bonus 8 Physician interpretation codes pay the HPSA bonus 9 Concept of PC TC does not apply do not pay the HPSA bonus ANES BASE VAL Anesthesia base value The anesthesia base values IAP HCPCS Type An M indicator will display when the HCPCS associated with the revenue line originated from the Medicare physician fee schedule MSI Multiple services indicator The value of 5 identifies services that are subject to the multiple procedure payment reduction MPPR ALLOWABLE REVENUE Allowable revenue codes The allowable revenue codes this HCPCS code may use in billing This is a four CODES position field When the last digit shows an X each variable for that revenue code is allowable If this field is blank the system will allow a HCPCS code on any revenue code HCPC DESCRIPTION HCPCS description The English narrative description of the HCPCS code Map 1772 Field Descriptions 60 RATE 60 reimbursement rate The rate the system will use for calculating reimbursement for the HCPCS 62 RATE or 62 REDU 62 lab reimbursement rate The rate the system will use for calculating rei
77. o select a specific code Press Enter to view Map 1822 m You can only select one code at a time MAP1822 XX XX XX XXXXXX PLAN CODE sc ADJUSTMENT REASON CODE UPDATE SCRN INQUIRY C201135E XX XX XX CLAIM TYPES I INPATIENT SNF O OUTPATIENT H HOME HEALTH CORF A ALL CLAIMS This change is due to an automated adjustment PRESS PF3 EXIT PF7 PREV PAGE CGS J15 MAC Part A REGION ACPFA052 MNT XXXXXX MMDDYY REASON CODE AA HIGLAS REASON CODE AA CLAIM TYPE A NARRATIVE 5 The Adjustment Reason Code Update Scrn Inquiry Map 1822 appears The difference between Map 1821 and Map 1822 is that Map 1822 allows you to see the full narrative 6 Press F7 to return to Map 1821 Field Descriptions for Option 16 Adjustment Reason Codes Map 1821 Field Descriptions MNT Identifies your operator ID and today s date For intermediary use only CLAIM TYPES Claim types The claim types identified for each adjustment reason code The claim types are l Inpatient SNF O Outpatient H Home Health CORF A All Claims PLAN CODE Plan Code For intermediary use only REASON CODE Adjustment reason code To review a particular adjustment reason code enter the adjustment reason code value in this field This field can be used instead of the S selection field described below Selection This field is used to make a selection to view information for a particular adjustment reason code
78. ocation in the S LOC field enables you to see all the claims in that particular area of FISS oeoa coon ccs Aahe Lie DIRECT DATA ENTRY ODE MANUAL NETEP A NQUIRY MENU MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI XXXXXXXXXX HIC PROVIDER S LOC P B9996 JTOB OPERATOR ID XXXXX FROM DATE TO DA DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS For information about FISS status and location codes refer to About Status Location Codes m found in Chapter 1 of this guide lf there are claims in the status location that you entered they will appear on Map 1741 after you press Enter There may be multiple beneficiaries listed This is normal since the common element you are inquiring about is the status code or status location code When you search by beneficiary HICN you are inquiring about that particular beneficiary therefore multiple beneficiaries will not be listed however multiple claims may display MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX sc CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI XXXXXXXXXX HIC PROVIDER S LOC P B9996 TOB OPERATOR ID XXXXXX FROM DATE TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC
79. onal Coverage Determination Response Code Identifies the response code that is returned from the NCD edits Valid values are default 0 the HCPCS diagnosis code matched the NCD edit table pass criteria The line continues through the internal local medical necessity edits 1 the line continues through the internal local medical necessity edits because the HCPCS code was not applicable to the NCD edit table process the date of services was not within the range of the effective dates for the codes the override indicator is set to Y or D or the HCPCS code field is blank 2 none of the diagnoses supported the medical necessity of the claim but the documentation indicator shows that the documentation to support medical necessity is provided The line suspends for medical review 3 the HCPCS diagnosis code matched the NCD edit table list CD 9 CM deny codes The line suspends and indicates that the service is not covered and is to be denied as beneficiary liable due to noncoverage by statute 4 none of the diagnosis codes on the claim support the medical necessity for the procedure and no additional documentation is provided This line suspends as not medically necessary and will be denied 5 diagnosis codes were not passed to the NCD edit module for the NCD HCPCS code The claim suspends and will move to the Return to Provider RTP file NCD National Coverage Determination Number This field identifies the NCD number
80. ou are in an inquiry or claim entry screen 2 The ICD 9 CM Code Inquiry screen Map 1731 appears MAP1731 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC ICD 9 CM CODE INQUIRY C201135E HH MM SS STARTING ICD9 CODE ICD9 CODE DESCRIPTION EFFECTIVE TERM DATE EFFECTIVE TERM DATE EFFECTIVE TERM DATE 3 To inquire about a diagnosis code enter the diagnosis code in the STARTING ICD9 CODE field and press Enter Do not type the decimal point or zero fill the code To review a complete list of diagnosis codes press Enter While FISS enables you to validate diagnosis codes you should still have a current ICD 9 CM coding book in your office Gae YA Ces Aia ie DIRECT DATA ENTRY DOE MANUAL Eee E INQUIRY MENU CHARTER 3 MAP1731 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX SC ICD 9 CM CODE INQUIRY C201135E XX XX XX STARTING tep9 cove 3630 ICD9 CODE DESCRIPTION EFFECTIVE TERM DATE EFFECTIVE TERM DATE EFFECTIVE TERM DATE 1630 MAL NEO PARIETAL PLEURA 100185 093012 1631 MAL NEO VISCERAL PLEURA 100185 093012 1638 MALIG NEOPL PLEURA NEC 100185 093012 1639 MALIG NEOPL PLEURA NOS 100185 093012 1640 MALIGNANT NEOPL THYMUS 100185 093012 1641 MALIGNANT NEOPL HEART 100185 093012 1642 MAL NEO ANT MEDIASTINUM 100185 093012 1643 MAL NEO POST MEDIASTINUM 100185 093012 PLEASE MAKE A SELECTION ENTER NEW KEY DATA PRESS PF3 EXIT PF6 SCROLL FWD If more than one of the
81. pated Payment RAPs when there is another insurer that is primary to Medicare HHAs do not receive payment for RAPs when there is another insurance that may pay primary to Medicare Number of days The number of days the claim has been in the Return to Provider RTP status This field is only functional through the Claim and Attachments Corrections Menu Refer to Chapter 5 of this guide for additional information Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL onsen NQUIRY Field Descriptions for Map 171A Map 171A Screen Example MENU MAPI71A PAGE 02 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX SC INST CLAIM INQUIRY C201135E XX XX XX DCN HIC RECEIPT DATE TOB STATUS LOCATION TRAN DT STMT COV DT TO SERV SERV REV HCPC MODIFIERS DATE RATE TOT UNT COV UNT TOT CHRG COV CHRG ANES CF ANES BV PC TC IND HCPC TYPE DEDUCTIBLES COINSURANCE ESRD RED VALCD 05 BLOOD CASH WAGE ADJ REDUCED PSYCH HBCF OTHER PAT gt MSP gt ANSI gt PAY HCPC MSP gt OUTLIER gt APC CD PAYER 1 PAYER 2 OTAF DENIAL OCE FLAGS MSP gt IND 1 2 3 4 5 6 7 8 9 ID gt REIMB RESP PAID REDUCT AMT ANSI PAT gt LABOR NON LABOR PROV gt MED gt PRICER PAY ASC ADJUSTMENT ANSI AMT RTC METHOD IDE NDC UPC GRP CONTR lt REASON CODES PRESS PF2 1712 PF3 EXIT PF5 UP PF6 DOWN PF7 PREV PF8 NEXT PF10 LEFT PF11 RIGHT Map 171A Field Descriptions Fields prior to the start of th
82. ple below shows how to access claims that were fully denied D B9997 with dates of service on and after October 1 2013 type the status location D B9997 in the S LOC field type 100113 in the FROM DATE field and leave the TO DATE field blank MAP1741 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC CLAIM SUMMARY INQUIRY C20112WS HH MM SS NPI NNNNNNNNNN PROVIDER S LOC D 89997 tos OPERATOR ID FROM DATE 080113 TO DATE DDE SORT MEDICAL REVIEW SELECT HIC PROV MRN S LOC TOB ADM DT FRM DT THRU DT REC DT SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC DAYS Accessing Additional Development Request ADR Information When claims are selected by Medical Review CGS will request additional documentation from the provider to support the services being billed to Medicare This request is called the Additional Development Request ADR http www cms gov Regulations and Guidance Guidance Manuals Downloads pim83c03 pdf requires providers to submit ADR documentation to CGS by day 30 If the documentation is not received timely the claim will be denied g NOTE The CMS Medicare Program Integrity Manual Pub 100 08 Ch 3 Section 3 2 3 2 The following pages explain how you can identify claims that CGS has requested additional documentation for what documentation is being requested and most importantly the due date for when the ADR information must be received Please refer to the
83. ptions Option 13 Revenue Codes Map 1761 Field Descriptions Revenue code A 4 digit field that represent the type of service supply or equipment being provided Effective date The date the revenue code became effective MMDDYY format Effective date indicator This date instructs the system to either use the from date of the claim or the system run date to perform edits for this revenue code Values are F Claim from date R Claim receipt date D Claim discharge date Termination date The date the revenue code became invalid MMDDYY format Narrative The English language description for the revenue code Type of bill The first two digits of the type of bill followed by an X denoting the frequency Allowable This field indicates whether the revenue code is valid for the type of bill Values are Y Yes N No Allowable effective date The date the revenue code became a valid code MMDDYY format HCPC Allowable termination date The date the revenue code was no longer valid MMDDYY format Healthcare Common Procedure Code System This field indicates whether the revenue code requires a HCPCS Values are Y Yes N No V Validation of HCPCS is required Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL oe NQUIRY MENU Map 1761 Field Descriptions EFF DT HCPCS effective date The beginning date th
84. reens F3 Exit return to the Inquiry Menu F7 Move one page back F8 Move one page forward 4 Start by entering the beneficiary s HICN as it appears on their Medicare card in the HIC field oS oS oO MMDDCCYY and press Enter Tab to the LN field Type the beneficiary s last name as it appears on their Medicare card Tab to the FN field Type the beneficiary s first name as it appears on their Medicare card Tab to the SEX field Type the gender of the beneficiary M male F female The cursor will automatically move to the DOB field Type the beneficiary s date of birth 9 The following example shows how the screen would look after entering the five identifying pieces of information but before pressing Enter Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL een NQUIRY MENU MAP1751 XXXXXX SC HIC 123456789A CGS J15 MAC Part A ELIGIBILITY DETAIL INQUIRY CURR XREF HIC REGION ACPFA052 MM DD YY C20112WS HH MM SS PREV XREF HIC TRANSFER HIC C IND LTR DAYS LN SMITH FN JOHN MI SEX M DOB 01011931 DOD ADDRESS 1 2 3 4 5 6 ZIP CURRENT ENTITLEMENT PART A EFF DT TERM DT PART B EFF DT TERM DT CURRENT FRST BILL DT SNF FULL DAYS BENEFIT PERIOD DATA LST BILL DT HSP FULL DAYS SNF PART DAYS INP DED REMAIN HSP PART DAYS BLD DED PNTS PSYCHIATRIC PSY DAYS REMAIN PRE PHY DAYS USED PSY DIS DT INTRM DT IND PLEASE ENTER
85. s why the bill was not paid 10 Invalid TOB 35 Invalid initial payment indicator 14 LUPA payment only 40 Invalid service thru date for current 15 Invalid PEP days for shortened episode calendar year 16 Invalid HRG days greater than 60 70 Invalid or no HRG code present 20 PEP indicator invalid 75 No HRG present in 1st occurrence 25 Medical review indicator invalid 80 Invalid revenue code 30 Invalid CBSA code 85 No revenue code present Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL enters MENU Map 171A Field Descriptions Fields prior to the start of the revenue code line item information first four rows of information are system generated from Page 01 of the claim PAY METHOD Payment Method Identifies the payment method returned from OCE Valid values are 1 paid standard OPPS amount status indicators S T V X or P 2 services not paid under OPPS status indicator A 3 not paid status indicators W Y or E or not paid under OPPS status indicators B C or Z 4 acquisition cost paid status indicator F 5 additional payment for drug or biological status indicator G 6 additional payment for device status indicator H 7 additional payment for new drug or new biological status indicator J 9 no additional payment included in line items with APCS status indicator N or no HCPCS code and certain revenue codes or HCPCS codes Q0082 activity
86. ted press your F8 key to review the reason code narrative on FISS Page 08 The edit that the claim was selected for will appear in the upper left hand corner Refer to the following page for an example of FISS Page 08 You may need to press F6 to see the remaining reason code narrative that identifies the documentation that you need to submit Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NQUIRY MENU Example FISS Page 08 r REASONS 59BX9 REASON CODE NARRATIVES FOR HIC DCN NNNNNNNNNA XXXXXXXXXXXXXXXXR 59BX9 MEDICARE NEEDS TO RECEIVE THE RETURNED ADR INFORMATION BY THE 30TH DAY THIS ALLOWS FOR MAIL TIME AND FOR US TO MOVE THE CLAIM INTO THE MEDICAL REVIEW STATUS LOCATION SM50MR BY DAY 45 OR IT WILL BE DENIED WITH REASON CODE 56900 ON THE 46TH DAY SEND THE FOLLOWING CHECK LIST OF INFORMATION TO SUPPORT THE TERMINAL ILLNESS AND SERVICES BILLED INITIAL ASSESSMENT ALL VISIT NOTES PLAN OF CARE CHANGES AND INTERDISCIPLINARY GROUP NOTES PHYSICIAN ORDERS AND VISIT NOTES HOSPITAL DISCHARGE AND OR PHYSICIAN SUMMARIES HISTORY AND PHYSICAL EXAM LAB X RAY AND OR SURGICAL REPORTS SIGNED DATED CERTIFICATION TRANSFER REVOCATIONS ANY PERTINENT INFORMATION PRIOR TO AFTER THIS BILLING PERIOD DATES AND TIMES OF SERVICE CHANGES WHEN BILLING MULTIPLE LEVELS OF CARE THE BENEFICIARY SIGNED AND DATED HOSPICE ELECTION STATEMENT SIGNED AND DATED HHABN OR NOTICE OF NON COVERAGE IF
87. therapy GO129 occupational therapy or G0177 partial hospitalization program services IDE NDC UPC Identifies IDE NDC and UPC ASC GRP Identifies the ASC group code for the indicated revenue code ACS Percentage Identifies the percentage used by the ASC Pricer in its calculation for the indicated revenue code Field Descriptions for Map 171D Map 171D Screen Example MAP171D PAGE 02 CGS J15 MAC Part A REGION ACPFA052 XX XX XX XXXXXX SC INST CLAIM INQUIRY C201135E XX XX XX DCN HIC RECEIPT DATE TOB STATUS LOCATION TRAN DT STMT COV DT TO PROVIDER ID BENE NAME NONPAY CD GENER HARDCPY MR INCLD IN COMP CL MR IND TPE TO TPE USER ACT CODE WAIV IND MR REV URC DEMAND REJ CD MR HOSP RED RCN IND MR HOSP RO ORIG UAC MED REV RSNS OCE MED REV RSNS HCPC MOD IN SERV 0000000 eR REASON CODES REV HCPC MODIFIERS DATE COV UNT COV CHRG ADR FMR ORIG ORIG REV MR ODC OCE OVR CWF OVR NCD OVR NCD DOC NCD RESP NCD OLUAC NON NON DENIAL OVER ST LC MED SeSeSseSsS ANS I LUAC COV UNT COV CHRG REAS CODE OVER TEC ADJ GRP Samana REMARKS TOTAL LINE ITEM REASON CODES lt REASON CODES PRESS PF2 1712 PF3 EXIT PF5 UP PF6 DOWN PF7 PREV PF8 NEXT PF10 LEFT Map 171D Field Descriptions SC Screen Control A feature that allows you to access other FISS inguiry options DCN Document Control Number Displays the claim s identification number assigned by FISS when the claim is received HIC
88. tly being processed in the system e Verify revenue codes diagnosis codes HCPCS codes adjustment reason codes reason codes and ANSI American National Standards Institute codes View the amount and payment date of the last three checks issued to your facility Access the Inquiry Menu 1 From the FISS Main Menu Map 1701 type 01 in the Enter Menu Selection field and press Enter MAP1701 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX MAIN MENU C20112WS HH MM SS 01 INQUIRIES 02 CLAIMS ATTACHMENTS 03 CLAIMS CORRECTION 04 ONLINE REPORTS ENTER MENU SELECTION 01 PLEASE ENTER DATA OR PRESS PF3 TO EXIT 2 The Inquiry Menu Map 1702 appears MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C20112WS HH MM SS BENEFICIARY CWF LO ZIP CODE FILE 19 DRG PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 15 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES L7 ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Enter the two characters for the inquiry option you want to access and press Enter All of the options are described in this chapter S20 Ge ahi cca Adohe Lie DIRECT DATA ENTRY DDE MANUAL IE 4 NQUIRY MENU All of the options are represented by two numerals except for OSC Reposi
89. tory Inquiry 1A and Check History Fl and Dx Proc Codes ICD 10 1B All FISS direct data entry DDE screens display two lines of information in the top right corner that identifies the region ACPFA052 the current date release number e g C20112WS and the time of day This information is for internal purposes only and is used to assist CGS staff in researching issues when screen prints are provided Beneficiary CWF Option 10 This option is helpful only if you need to view the beneficiary s address The beneficiary s address is not available on the CWF Common Working File eligibility screens ELGA and ELGH but is available by using this option 1 From the Inquiry Menu type 10 in the Enter Menu Selection field and press Enter MAP1702 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX INQUIRY MENU C20112WS HH MM SS BENEFICIARY CWF 10 ZIP CODE FILE 19 DRG PRICER GROUPER L1 OSC REPOSITORY INQUIRY 1A CLAIM SUMMARY 12 CLAIM COUNT SUMMARY 56 REVENUE CODES 13 HOME HEALTH PYMT TOTALS 67 HCPC CODES 14 ANSI REASON CODES 68 DX PROC CODES ICD 9 L5 CHECK HISTORY FI ADJUSTMENT REASON CODES 16 DX PROC CODES ICD 10 1B REASON CODES L7 ENTER MENU SELECTION PLEASE ENTER DATA OR PRESS PF3 TO EXIT Although this option includes several screen pages with eligibility information only screen examples and field descriptions for the first screen page are explained below The remaining screen pages should not be us
90. ubmitted the information Pages 07 and 08 will no longer display after the documentation is received and the claim is moved from status location S B6001 to S M50MR For information on how to screen print FISS claim pages refer to the FISS Overview chapter of this guide 8 Press F3 to exit back to Map 1741 or press F7 to move back through the claim pages If you have additional claims in the ADR status location you must select each claim individually to determine what documentation needs to be submitted to CGS and by what date You may want to refresh your screen to ensure accurate information displays Press F3 to exit option 12 Then type 12 in the Enter Menu Selection field and press Enter Retype your NPI and the status location S B6001 in the S LOC field You are responsible for checking your claims to see if they are in the ADR status location as this is the only notification you will receive regarding your claims that have been selected for Medical Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL NQUIRY MENU Review by CGS In addition you should keep track of the claims for which you have submitted ADR documentation Key ADR Information e CMS requires providers to submit ADR documentation to CGS by day 30 However CGS must receive and process the additional information by the 45th day after the date of request Orig Req Dt shown on FISS Page 0
91. xample that the cursor is one space away from or to the left of the HICN of the claim detail you want to select If the cursor is immediately next to the HICN _123 instead of _ 123 the cursor is not in the correct position Created August 22 2014 2014 Copyright CGS Administrators LLC DIRECT DATA ENTRY DDE MANUAL INQUIRY MENU CHAPTER 3 e Page 01 of the Inst Claim Inquiry screen appears You may view all pages of the claim by pressing the F7 and F8 function keys to page back and page forward through the claim Refer to the following page for an example of page 01 of the claim Claim Example MAP1711 PAGE 01 CGS J15 MAC Part A REGION ACPFA052 MM DD YY XXXXXX SC INST CLAIM INQUIRY C20112WS HH MM SS HIC 123456789A TOB XXX S LOC P B9997 OSCAR XXXXXX SV UB FORM NPI XXXXXXXXXX TRANS HOSP PROV PROCESS NEW HIC PAT CNTL TAX SUB TAXO CD STMT DATES FROM 0817XX TO 1015XX DAYS COV N C CO LTR LAST SMITH FIRST JAMES MI E DOB 01011931 ADDR 1 101 MAIN ST 2 ANYTOWN IA 3 4 CARR 5 6 LOC ZIP 520012233 SEX M MS ADMIT DATE 0817XX HR 01 TYPE 9 SRC 1 D HM STAT 30 COND CODES 01 02 03 04 05 06 07 08 09 10 OCC CDS DATE 01 02 03 04 05 06 07 08 09 10 SPAN CODES DATES 01 02 03 04 05 06 07 08 09 10 FAC ZIP 52111 DCN VALUE CODES AMOUNTS ANSI MSP APP IND 01 61 99916 00 02 03 04 05 06 07 08 09 37186 lt REASON CODES PRESS PF3 EXIT PF5 SCROLL BKWD PF6 SCROLL FWD PF8 NEXT PF9 UPDT f After reviewing
92. y use only HD CPY A B For intermediary use only NB ADR For intermediary use only CAL DY For intermediary use only C L For intermediary use only NARRATIVE Narrative for the specific reason code Map 1882 Field Descriptions MNT Identifies the last operator who created or revised this screen and the date For intermediary use only REASON CODE Reason code The reason code identifies a specific condition assigned to the claims during processing PIMR ACTIVITY CODE Program integrity management reporting PIMR activity code The PIMR activity code for which the reason code is being categorized Valid values are Al Automated CCI edit AL Automated locally developed edit AN Automated national edit CP Prepay complex probe review DB TPL or demand bill claim review MR Manual routine review PS Prepay complex provider specific review RO Reopening ss Prepay complex service specific review DENIAL CODE PIMR denial reason code The denial reason code for which the reason code is being categorized Valid values are 100001 Documentation Does Not Support Service 100002 Investigation Experimental 100003 Item Services Excluded From Medicare Coverage 100004 Requested Information Not Received 100005 Services Not Billed Under The Appropriate Revenue Or Procedure Code Include Denials Due To Unbundling In This Category 100006 Services Not Documented In Record 100007 Services Not Medically Reasonable And Necessary 10000

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