Durable Medical Equipment, Prosthetics/Orthotics & Supplies Fee Schedule
Medicare is proposing to clarify the 3-year minimum lifetime requirement (MLR) for Durable Medical Equipment (DME) and the definition of routinely purchased DME. This rule also proposes the implementation of budget-neutral fee schedules for splints and casts, and intraocular lenses (IOLs) inserted in a physician’s office. Finally, this rule would make a few technical amendments and corrections to existing regulations related to payment for DMEPOS items and services in the End-Stage Renal Disease Prospective Payment System Proposed Rulemaking. View CMS-1526-P .
Diabetic Testing Supplies Provisions of the American Taxpayer Relief Act of 2012
On Wednesday, January 2, 2013, the President signed into law the American Taxpayer Relief Act of 2012. Section 636 of this new law revises the Medicare non-mail order fee schedule amounts for diabetic testing supplies. Effective for items furnished on or after April 1, 2013, the non-mail order fee schedule amounts for Healthcare Common Procedure Coding System (HCPCS) codes A4233, A4234, A4235, A4236, A4253, A4256, A4258 and A4259 will be recalculated by removing the 5 percent covered item update for calendar year 2009 and applying a 9.5 percent reduction. This will result in the fee schedule amounts for non-mail order diabetic testing supplies being equal to the fee schedule amounts for mail order diabetic testing supplies (denoted by KL modifier). In addition, effective for items furnished on or after the date of implementation of the national mail order competitions of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program, the new law requires that the Medicare non-mail order fee schedule amounts for diabetic testing supplies be adjusted so that they are equal to the single payment amounts established under the national mail order competition for diabetic testing supplies. Rules related to assignment of claims for non-mail order diabetic testing supplies are not affected by this new law.
Given the new legislation, CMS expects to no longer consider the application of its inherent reasonableness authority for the Medicare fee schedule amounts for non-mail order diabetic testing supplies. Additional information about the fee schedule changes for non-mail order diabetic testing supplies will be provided in the April 2013 DMEPOS Fee Schedule Update that will be posted on the CMS transmittals website: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/index.html The April quarterly update to the fee schedule file is generally available in late February and is posted on the CMS website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.
Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule Amounts for Non-Mail Order (Retail) Diabetic Testing Supplies
Monday, July 23; 9am-1pm ET
CMS hosted a public meeting on July 23, 2012 that provided an opportunity for consultation with representatives of suppliers and other interested parties regarding options to adjust the Medicare payment amounts for non mail order diabetic testing supplies. An audio recording and written transcript of the meeting are now available in the Downloads section below. The audio begins at the 16:30 mark.
Please note that the deadline for submission of written comments has been extended to 5 p.m. EDT on Friday, August 10, 2012. Written comments may either be emailed to DMEPOS@cms.hhs.gov or sent via regular mail to Elliot Klein, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mail Stop C5-03-17, Baltimore, MD 21244-1850.
View the Federal Register Notice: Public Meeting Regarding Inherent Reasonableness of Medicare Fee Schedule Amounts for Non-Mail Order (Retail) Diabetic Testing Supplies (CMS-1445-N) [Published: June 26, 2012].
Changes in Medicare Payment for Oxygen and Oxygen Equipment
Medicare payment for durable medical equipment (DME), prosthetics and orthotics (P&O), parenteral and enteral nutrition (PEN), surgical dressings, and therapeutic shoes and inserts is equal to 80 percent of the lower of either the actual charge for the item or the fee schedule amount calculated for the item, less any unmet deductible. The beneficiary is responsible for 20 percent of the lower of either the actual charge for the item or the fee schedule amount calculated for the item, plus any unmet deductible. The DME and P&O fee schedule payment methodology is mandated by section 4062 of the Omnibus Budget Reconciliation Act (OBRA) of 1987, which added section 1834(a) to the Social Security Act. OBRA of 1990 added a separate subsection, 1834(h), for P&O. The DME and P&O fee schedules were implemented on January 1, 1989 with the exception of the oxygen fee schedules, which were implemented on June 1, 1989. Section 13544 of OBRA of 1993, which added section 1834(i) to the Social Security Act, mandates a fee schedule for surgical dressings; the surgical dressing fee schedule was implemented on January 1, 1994. Section 4315 of the Balanced Budget Act of 1997, which added section 1842(s) to the Social Security Act, authorizes a fee schedule for PEN, which was implemented on January 1, 2002. Section 627 of the Medicare Modernization Act of 2003 mandates fee schedule amounts for therapeutic shoes and inserts effective January 1, 2005, calculated using the P&O fee schedule methodology in section 1834(h) of the Social Security Act.
Who should you contact to determine which HCPCS code to use for billing?
PDAC Helpline: 877-735-1326
DURABLE MEDICAL EQUIPMENT (DME) CENTER
For a one-stop resource web page focused on the informational needs and interests of Medicare Fee-for-Service (FFS) DMEPOS suppliers, go to the DME Center (see under "Related Links Inside CMS" below).
- CY 2009 Physician Fee Schedule (PFS) Final Rule with Comment: CMS-1403-FC Page 70163 (Final Rule and Associated Data Files)
- Durable Medical Equipment (DME) Center
- National Heritage Insurance Company (NHIC) DME MAC - Jurisdiction A - Opens in a new window
- National Government Services DME MAC - Jurisdiction B - Opens in a new window
- CGS Administrators, LLC DME MAC - Jurisdiction C - Opens in a new window
- Noridian DME MAC - Jurisdiction D - Opens in a new window
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