MLN Matters® Number: MM6762
Related Change Request (CR) #: 6762
Related CR Release Date: February 5, 2010
Effective Date: May 5, 2010
Related CR Transmittal #: R636OTN
Implementation Date: May 5, 2010
Provider Types Affected
This article is for physicians, producers, and suppliers billing Medicare Carriers and Medicare Administrative Contractors (A/B MACs) for certain durable medical equipment (DME) products provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 6762 which provides instructions to Medicare contractors for recouping funds for any payments made to durable medical equipment prosthetics, orthotics and supplies (DMEPOS) suppliers for implanted DME or implanted prosthetics, based on the revised list of HCPCS codes payable as a replacement part, accessory or supply for prosthetic implants and surgically implanted DME provided in CR 6573. Medicare contractors will continue to pay claims for replacement parts, accessories and supplies for prosthetic implants and surgically implanted DME based on the supplier’s location. (See CR 6573 for the revised list of HCPCS codes at http://www.cms.hhs.gov/Transmittals/downloads/R531OTN.pdf that may be paid as replacement part, accessory or supply for prosthetic implants and surgically implanted DME under the guidelines established in CR 5917.) Be sure billing staff are aware of these Medicare changes.
Background
The Centers for Medicare & Medicaid Services (CMS) issued CR 6762 in order to augment previously issued CR 6573. CR 6573 instructed contractors to use the revised list to determine the items that may be billed under the guidelines established in CR 5917 which may be reviewed at http://www.cms.hhs.gov/Transmittals/downloads/R1603CP.pdf
at on the CMS website.
CR 6573 clarified that the filing jurisdiction for claims submitted under the guidelines established in CR 5917 is determined by the supplier’s location and that the payment for these items is based on the fee schedule amount for the State where the beneficiary maintains their permanent residence.
In CR 5917, CMS instructed Medicare contractors to process and pay claims for replacement parts, accessories and supplies for prosthetic implants and surgically implanted DME when submitted by suppliers that are enrolled with both the National Supplier Clearinghouse (NSC) and their local carrier/A/B MAC.
Although CR 5917 reinstated the local carrier and A/B MAC jurisdiction for claims for these items, the instruction was not clear about the claims filing jurisdiction or the payment rules that apply when the beneficiary resides outside of the local carrier or A/B MAC’s jurisdiction. In addition, Attachment A of CR 5917 included an excerpt of the 2008 annual jurisdiction list containing Healthcare Common Procedure Coding System (HCPCS) codes, which CMS previously instructed may be billed to the carrier or A/B MAC as a replacement part, accessory or supply for prosthetic implants and surgically implanted DME. It has since come to CMS’ attention that this list included codes for implanted devices, which may not be separately billed to the carrier/A/B MAC by DMEPOS suppliers. Attachment A of CR 5917 was replaced by a revised list of HCPCS codes in Attachment A of CR 6573. The web links to CR 5917 and CR 6573 are listed above.
Key Points of CR 6762
- Medicare contractors will pay claims for items subject to the guidelines in CR 5917 based on the supplier’s location per the revised list of HCPCS codes included in Attachment A of CR 6573.
- To the extent possible, Medicare contractors will reopen and reprocess claims for implanted DME and or implanted prosthetics for dates of service between October 27, 2008, and December 31, 2009 and they will recoup any overpayments made to DMEPOS suppliers for implanted DME or implanted prosthetics based on using the original list of HCPCS codes included in Attachment A of CR 5917.
- CR 6762 and the billing guidelines for replacement parts, accessories or supplies for implanted devices established in CR 5917 apply only to DMEPOS suppliers enrolled with the NSC and their local carrier or A/B MAC and does not change the existing carrier or A/B MAC billing rules that apply to physicians, facilities, or other entities that are implanting the devices.
Additional Information
on the CMS website.
If you have questions, please contact the Palmetto GBA Provider Contact Center at (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association.