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Durable Medical Equipment (DME) Center

Spotlights
  • Medicare DMEPOS Competitive Bidding contract suppliers for Round 2 Recompete and the national mail-order recompete for diabetes testing supplies have been announced.  View the fact sheet.
  • List of Codes Affected by PAMPA

The Centers for Medicare & Medicaid Services has released the list of HCPCS codes for wheelchair accessories affected by the Patient Access and Medicare Protection Act (PAMPA).  Section 2 of PAMPA mandates that adjustments to the 2016 Medicare fee schedule amounts for certain durable medical equipment (DME) based on information from competitive bidding programs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs. CMS welcomes public input on this list.  The list should only include codes for wheelchair accessories that can be used with Group 3 complex rehabilitative power wheelchairs and had revised fee schedule amounts calculated for 2016 based on information from competitive bidding programs.

View list of codes [ZIP, 13KB]

  • CMS has announced the Medicare DMEPOS Competitive Bidding single payment amounts for Round 2 Recompete and national mail-order recompete and has begun sending contract offers.  For additional information, visit the Competitive Bidding Implementation Contractor website.
  • Implementation of Section 2 of the Patient Access and Medicare Protection Act Fact Sheet

CMS is implementing the Patient Access and Medicare Protection Act to ensure that beneficiaries have access to wheelchair accessories and seat and back cushions when furnished with Group 3 complex rehabilitative power wheelchairs.  To ensure beneficiary access to these accessories particularly for these vulnerable populations, advance payment may be available for suppliers.  Prior to July 1, suppliers will be paid the adjusted fee schedule rates. The average reduction during this period for these items is approximately 10%. During this time, CMS has announced that suppliers are able to submit a single advance payment request for multiple claims if the conditions described in CMS regulations at 42 CFR Section 421.214 are met. Additional information is below.

MESSAGE TO SUPPLIERS

The Patient Access and Medicare Protection Act (PAMPA) was recently signed into law on December 28, 2015.  Beginning January 1, 2016, the DME fee schedule rates are adjusted to reflect information from the DMEPOS competitive bidding program as required by section 1834(a)(1)(F)(ii) of the Social Security Act.  These adjustments are being phased in during the initial 6 months of 2016 so that the fee schedule amounts in all areas will be based on a 50/50 blend of current rates and adjusted rates. Section 2 of PAMPA mandates that adjustments to the 2016 Medicare fee schedule amounts for certain durable medical equipment (DME) based on information from competitive bidding programs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs.  Group 3 complex rehabilitative power wheelchair bases are currently described by codes K0848 through K0864 of the Healthcare Common Procedure Coding System (HCPCS).

Although this change is effective January 1, 2016, changes to the Medicare claims processing systems cannot be implemented any sooner than July 1, 2016.  Until these changes are implemented, payment for these items will be based on the adjusted fee schedule amounts. Suppliers can submit claims for these items with dates of service on or after January 1, 2016, but payment will be based on the adjusted fee schedule amounts.  On or after July 1, 2016, suppliers can adjust previously paid claims with dates of service on or after January 1, 2016, to receive the full fee schedule amount. For these items, the average adjustments to the 2016 rates in the transition period is about a reduction of 10 percent.

Additional information, including a list of HCPCS codes for accessories affected by this change, as well as further instructions regarding the submission and processing of these claims, will be provided in the coming months. https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html

Because the changes to the Medicare claims processing system cannot be implemented any sooner than July 1, the Part B Medicare contractors are unable to process claims within established time limits and an advance payment may be available.  Suppliers are able to submit a single advance payment request for multiple claims for an eligible period of time.  Note an advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met.

To apply for an advance payment, the Medicare supplier is required to submit the request to their appropriate Medicare Administrative Contractor.  CMS will not make advance payments in the case where a supplier is unable to submit a valid claim for services rendered.

  • Corrections Being Made to the 2016 DMEPOS Fee Schedule Amounts for Certain Items

On November 23, 2015, CMS released the 2016 Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule amounts. The DMEPOS and PEN public use files contain fee schedules for certain items that were adjusted based on information from the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program in accordance with Section 1834(a)(1)(F) and 1842(s)(3)(B) of the Act.  CMS identified errors in the fee schedule amounts for some items and has therefore released revised fee schedule files on December 8, 2015.  A list of the codes affected by the revisions is included as a separate public use file along with the revised 2016 fee schedule public use files. In addition, errors were identified in the Fact Sheet under the “Examples of New Payment Rates for January” chart for the contiguous United States.  Under the 2016 blended urban fee column, the average 2016 blended fees for codes E0163, E0730 and E0784 have been revised.  Please be aware that on December 14, 2015, CMS replaced the December 8, 2015 PEN text file (DMEPEN_JAN_V1208) to correct format errors.

For additional information:

  • CMS Announces the Release of the 2016 DMEPOS Fee Schedules that Include Adjusted Fees Based on DMEPOS Competitive Bidding Program Information

On November 23, 2015, CMS announced the release of the 2016 Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule amounts.  The DMEPOS and PEN public use files contain fee schedules for certain items that were adjusted based on information from the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program in accordance with Section 1834(a)(1)(F) and 1842(s)(3)(B) of the Act. 

For additional information:

  • Durable Medical Equipment Prosthetics Orthotics Supplies (DMEPOS) Rural Zip Code File & Fee Schedule Public Use File Formats

The Centers for Medicare and Medicaid Services (CMS) has released revised PUF formats for the CY 2016 DMEPOS and Parenteral and Enteral Nutrition (PEN) fee schedules.  Also released is a preliminary DMEPOS rural ZIP Code file containing Quarter 4 2015 rural ZIP codes.  Beginning January 1, 2016, fee schedule amounts for certain items will be adjusted based on information from the DMEPOS competitive bidding program, and for some items, the adjusted fee schedule amounts for items furnished in rural areas within the state will be different than the adjusted fee schedule amounts in other areas of the state.  The ZIP codes for areas defined as rural areas per regulations at 42 CFR 414.202 are based on current ZIP code boundaries.  Changes to the ZIP code public use file will be made, as needed, based on future changes to ZIP codes by the United States Postal Service.  The public use files for the DMEPOS and PEN fee schedules do not contain fee schedule amounts, but are being posted to show what changes are being planned for the file formats to accommodate the fee schedule amounts for rural areas, as well as statewide fee schedule amounts for enteral nutrition. Please be aware that effective October 21, 2015, revised 2016 DME and PEN TEXT file formats were made available as part of an updated DMEREADLAYOUTS16 document.  

The revised TEXT files and the other PUF formats are available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.    

  • Final Decision Memorandum for Speech Generating Devices

On July 29, 2015, the Centers for Medicare & Medicaid Services (CMS) posted a final decision memorandum related to the coverage of speech generating devices.  To view the final decision memorandum, please visit the following CMS web page: Speech Generating Devices.

  • Additional Time to Establish Protocols for Newly Required Face-to-Face Encounters for DME

Due to concerns that some providers and suppliers may need additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for certain items of Durable Medical Equipment (DME), CMS will start actively enforcing and will expect full compliance with the DME face-to-face requirements beginning on October 1, 2013.

Section 6407 of the ACA established a face-to-face encounter requirement for certain items of DME. The law requires that a physician must document that a physician, nurse practitioner, physician assistant, or clinical nurse specialist has had a face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME.

Although many DME suppliers and physicians are aware of and are able to comply with this policy, CMS is concerned that some may need additional time to establish operational protocols necessary to comply with this new law.  As such, CMS expects that during the next several months, suppliers and physicians who order certain DME items will continue to collaborate and establish internal processes to ensure compliance with the face-to-face requirement. CMS expects durable medical equipment suppliers to have fully established such internal processes and have appropriate documentation of required encounters by October 1, 2013.  

CMS will continue to address industry questions concerning the new requirements and will update information on our Medical Review and Education website. CMS and its contractors will also use other communication channels to ensure that the provider community is properly informed of this announcement.

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Important Links

Competitive Bidding

CMS Manuals & Transmittals

DME MAC Supplier Manuals

National Provider Identifier (NPI)

Coding

Program Integrity/ Medical Review

Fraud & Abuse

  • Beneficiary Complaint Response Program

Education

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