Palmetto GBA - Ohio Part B Carrier - Fee Schedule Update for 2009 for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Fee Schedule Update for 2009 for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

MLN Matters Number: MM6270 Revised

Related Change Request (CR) #: 6270

Related CR Release Date: November 7, 2008

Effective Date: January 1, 2009

Related CR Transmittal #: R1630CP

Implementation Date: January 5, 2009

Note: This article was revised on December 3, 2008 to clarify language in the second paragraph of page 5. The revised language more completely explains the rationale for the revised 2009 monthly national payment rate for stationary oxygen equipment. All other information remains the same.

Provider Types Affected

Providers and suppliers submitting claims to Medicare contractors (carriers, DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for DMEPOS provided to Medicare beneficiaries.

Provider Action Needed

This article is based on Change Request (CR) 6270 and alerts providers that the Centers for Medicare & Medicaid Services (CMS) has issued instructions for implementing and/or updating the DMEPOS fee schedule payment amounts on a semiannual basis (January and July), with quarterly updates as necessary (April and October). Be sure your billing staffs are aware of these changes.

Background

The update process for the DMEPOS fee schedule is contained in section 60, Chapter 23 of the Medicare Claims Processing Manual, which is located at www.cms.hhs.gov/manuals/downloads/clm104c23.pdf (PDF, 1.28 MB). Other information on the fee schedule, including access to the DMEPOS fee schedules is at www.cms.hhs.gov/DMEPOSFeeSched/01_overview.asp. The key points of CR 6270 are as follows:

The following codes are being deleted from the Healthcare Common Procedure Coding System (HCPCS) effective January 1, 2009, and are therefore being removed from the DMEPOS fee schedule files:

HCPCS Codes
L5993	L5994	L5995	L7611	L7612	L7613
L7614	L7621	L7622

For gap-filling purposes, the 2008 deflation factors by payment category are:

2008 Deflation Factors
0.500 for Oxygen	0.504 for Capped Rental	0.505 for Prosthetics and Orthotics	0.641 for Surgical Dressings	0.697 for Parental and Enteral Nutrition

The fee schedule amounts for HCPCS code K0672 (Addition to Lower Extremity Orthosis, Removable Soft Interface, All Components, Replacement Only, Each) are added to the fee schedule file on January 1, 2009, and are effective for claims submitted with dates of service on or after January 1, 2009.
HCPCS code E2295 (Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features) is added to the HCPCS file on January 1, 2009. Due to low claims volumes expected, your Medicare contractor will establish local fee schedule amounts to pay claims for HCPCS code E2295.
Fee schedule amounts for HCPCS codes L3905, L3806, and L3808 were revised in the July 2008 Quarterly Update. However, CMS has determined that the gap-filled fees originally established for these three codes were correct and the fee amounts will revert back to what was in place prior to the July update. Claims already processed for dates of service on or after July 1, 2008, through December 31, 2008 will not be adjusted.

2009 Fee Schedule Updates following the Enactment of the Medicare Improvements for Patients and Providers Act (MIPPA)

MIPPA of 2008 mandates a fee schedule covered item update of -9.5% for 2009 for items included in round 1 of the DMEPOS Competitive Bidding Program. The reduction applies to items furnished on or after January 1, 2009, in any geographical area.
Items selected for competitive bidding in 2008 will receive a -9.5% update for 2009 with the exception of HCPCS codes E1392, K0738, E0441, E0442, E0443 and E0444. These 6 oxygen generating portable equipment (OGPE) and oxygen contents codes will receive a 0% update for 2009 as the fees for these items are not adjusted by the covered item update specified in 1834(a)(14), and are not reduced by the -9.5%, even though they are competitive bid items.
Non-competitive bid items will receive a 5.0% covered item update for 2009.

New KE Modifier and the KL Modifier

A new HCPCS modifier was added to the HCPCS on January 1, 2009, and is effective for claims with dates of service on or after January 1, 2009. The new HCPCS modifier is KE (Bid Under Round One of the DMEPOS Competitive Bidding Program for use with Non-Competitive Bid Base Equipment).

To accommodate the fee schedule updates required per the MIPPA, CMS is adding the KE HCPCS modifier to the fee schedule for all power mobility device (PMD) accessory items selected for competitive bidding in 2008 as part of this update. The KE HCPCS modifier is a pricing modifier that suppliers must use to identify when the same accessory HCPCS code can be furnished in multiple competitive and non-competitive bidding product categories. For example, HCPCS code E0981 Wheelchair Accessory, Seat Upholstery, Replacement Only, Each can be used with both competitively bid standard and complex rehabilitative power wheelchairs (HCPCS codes K0813 thru K0829 and K0835 thru K0864), as well as with non-competitively bid manual wheelchairs (HCPCS codes K0001 thru K0009) or a miscellaneous power wheelchair (HCPCS code K0898).

All fee schedules for PMD accessory codes with the KE HCPCS modifier will receive a 5% covered item update for 2009, whereas the fee schedules for the PMD accessory codes without the KE HCPCS modifier will receive the MIPPA-required 9.5% reduction for 2009. Suppliers need to know that if a competitively bid PMD accessory code is used with a competitively bid standard PMD base code (HCPCS codes K0813 thru K0829) or complex rehabilitative PMD base code (HCPCS codes K0835 thru K0864), claims for the PMD accessory code should be submitted without the KE HCPCS modifier. If such claims are submitted with the KE HCPCS modifier, they will be rejected with message M78 (Missing/incomplete/invalid HCPCS modifier) and 125 (Submission/billing error (s)).

Suppliers should bill the accessory code with the KE HCPCS modifier when the accessory is used in conjunction with a non-competitively bid manual wheelchair (HCPCS codes K0001 through K0009) or a miscellaneous PMD (HCPCS code K0898). In the case of the complex rehabilitative only PMD accessory HCPCS code/modifier E2373 KC, suppliers should bill for the replacement only of HCPCS E2373 without the KE HCPCS modifier, but with the KC HCPCS modifier when the accessory is used with a competitively bid complex rehabilitative PMD base code (HCPCS codes K0835 thru K0864). When the replacement only code E2373 is used with a non-competitively bid manual or miscellaneous wheelchair, suppliers should bill HCPCS code E2373 without the KC HCPCS modifier, but with the KE HCPCS modifier.

For the aforementioned reasons, CMS is also adding the KE HCPCS modifier to the fee schedule for the following competitively bid HCPCS codes: A4636, A4637, A7000, and E0776. If HCPCS codes A4636 and A4637 are used in conjunction with a competitively bid walker code (E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, and E0149), claims for the replacement handgrip (A4636) or tip (A4637) should be submitted without the KE HCPCS modifier. Suppliers should bill codes A4636 and A4637 with the KE HCPCS modifier when the codes are used with non-competitively bid cane or crutch codes. Likewise, suppliers should bill the disposable canister code A7000 without the KE modifier when this code is used in conjunction with the competitively bid negative pressure wound therapy pump code E2402. When HCPCS code A7000 is used with a non-competitively bid respiratory or gastric suction pump, suppliers should bill code A7000 with the KE HCPCS modifier. Similarly when an IV pole (E0776) is used in conjunction with competitively bid enteral nutrient codes (B4149, B4150, and B4152 thru B4155), suppliers should bill HCPCS code E0776 with the BA HCPCS modifier, but without the KE HCPCS modifier. When HCPCS code E0776 is used with non-competitively bid parenteral nutrient codes, suppliers should bill HCPCS code E0776 without the BA HCPCS modifier, but with the KE HCPCS modifier.

Further instruction on the use of the KE HCPCS modifier with codes competitively bid in 2008 is available in Attachment B of CR 6270, which is available at www.cms.hhs.gov/Transmittals/downloads/R1630CP.pdf (PDF, 103 KB) on the CMS Web site.

Note: Suppliers should not use the KE HCPCS modifier on any claims for payment for items that were included under Round 1 such as an accessory for a standard power wheelchair.

With CR 6270, CMS is also adding the KL HCPCS modifier to the fee schedule for the following diabetic supply HCPCS codes: A4233, A4234, A4235, A4236, A4253, A4256, A4258, and A4259. As indicated in CR 5641 (July Quarterly Update for 2007 DMEPOS Fee Schedule, discussed in MLN Matters article MM 5641 at

www.cms.hhs.gov/Transmittals/downloads/R1630CP.pdf (PDF, 103 KB)), suppliers began using the KL HCPCS modifier as an informational modifier to identify diabetic supplies (HCPCS codes A4233-A4236, A4253, A4256, A4258 and A4259) furnished via mail order on or after July 1, 2007.

Effective January 1, 2009, the KL HCPCS modifier has been changed from an informational modifier to a pricing modifier in the HCPCS file. Suppliers must use the KL HCPCS modifier on all claims for the aforementioned diabetic supply codes that are furnished via mail order to beneficiaries. The KL HCPCS modifier is not used with diabetic supply codes that are not delivered to the beneficiary’s residence and are obtained from local supplier storefronts.

Note: Inappropriate use of a competitive bidding modifier on a competitive bidding claim is in violation of the law and may lead to claims denial and/or other corrective actions. The use of a competitive bidding modifier does not supersede existing Medicare modifier use requirements for a particular code, but rather should be used in addition, as required.

Competitive Bidding Items from 2008 Impacted by 2009 Pricing

The following product lists of the HCPCS codes that were selected for competitive bidding in 2008 are subject to the - 9.5% covered item update for 2009. The detailed descriptions of the listed HCPCS codes (for product categories 1-10) are not repeated in this article, but are available in Attachment A of CR 6270, which is available at

http://www.cms.hhs.gov/Transmittals/downloads/R1630CP.pdf.

Product Category 1—Oxygen, Supplies and Equipment (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Codes
E1390	E1391	E0424	E0439	E0431
E0434	A4608	A4615	A4616	A4617
A4620	E0560	E0580	E1353	E1355

As part of this update, CMS is implementing the 2009 national monthly payment rates for stationary oxygen equipment (HCPCS codes E0424, E0439, E1390 and E1391), effective for claims with dates of service on or after January 1, 2009. CMS is revising the fee schedule file to include the new national 2009 monthly payment rate of $175.79 for stationary oxygen equipment. This revised 2009 monthly payment rate of $175.79 is reduced by 11.8% from the 2008 monthly payment rate.

This reduction includes the 9.5% covered item reduction ascribed to items selected for competitive bidding in 2008 as required by section 154(a)(2)(A) of MIPPA and the 2.53 percent budget neutrality reduction as required by section 1834(a)(9)(D)(ii) of the Social Security Act and discussed in a final rule published in the Federal Register on November 9, 2006. The previously announced payment amount for 2009 of $193.21 did not include the 9.5% reduction and assumed a higher shift to
oxygen generating portable equipment (OGPE).

As a result of the above adjustments, CMS is also revising the fee schedule amounts for HCPCS codes E1405 and E1406 as part of this update. Since 1989, the fees for HCPCS codes E1405 and E1406 have been established based on a combination of the Medicare payment amounts for stationary oxygen equipment and nebulizer HCPCS codes E0585 and E0570, respectively.

Product Category 2-Standard Power Wheelchairs, Scooters, and Related Accessories (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Codes
E0950	E0951	E0952	E0955	E0956	E0957	E0960	E0973
E0978	E0981	E0982	E0990	E0995	E1016	E1020	E1028
E2208	E2209	E2210	E2361	E2363	E2365	E2366	E2367
E2368	E2369	E2370	E2371	E2381	E2382	E2383	E2384
E2385	E2386	E2387	E2388	E2389	E2390	E2391	E2392
E2394	E2395	E2396	E2601	E2602	E2603	E2604	E2605
E2606	E2607	E2608	E2611	E2612	E2613	E2614	E2615
E2616	E2619	E2620	E2621	K0015	K0017	K0018	K0019
K0020	K0037	K0038	K0039	K0040	K0041	K0042	K0043
K0044	K0045	K0046	K0047	K0050	K0051	K0052	K0053
K0098	K0195	K0733	K0734	K0735	K0736	K0737	K0800
K0801	K0802	K0806	K0807	K0808	K0813	K0814	K0815
K0816	K0820	K0821	K0822	K0823	K0824	K0825	K0826
K0827	K0828	K0829

Product Category 3-Complex Rehabilitative Power Wheelchairs and Related Accessories (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Codes
E0950	E0951	E0952	E0955	E0956	E0957	E0960	E0973
E0978	E0981	E0982	E0990	E0995	E1002	E1003	E1004
E1005	E1006	E1007	E1008	E1010	E1016	E1020	E1028
E1029	E1030	E2208	E2209	E2210	E2310	E2311	E2321
E2322	E2323	E2324	E2325	E2326	E2327	E2328	E2329
E2330	E2351	E2361	E2363	E2365	E2366	E2367	E2368
E2369	E2370	E2371	E2374	E2375	E2376	E2377	E2381
E2382	E2383	E2384	E2385	E2386	E2387	E2388	E2389
E2390	E2391	E2392	E2394	E2395	E2396	E2601	E2602
E2603	E2604	E2605	E2606	E2607	E2608	E2611	E2612
E2613	E2614	E2615	E2616	E2619	E2620	E2621	K0015
K0017	K0018	K0019	K0020	K0037	K0038	K0039	K0040
K0041	K0042	K0043	K0044	K0045	K0046	K0047	K0050
K0736	K0737	K0835	K0836	K0837	K0838	K0839	K0840
K0841	K0842	K0843	K0848	K0849	K0850	K0851	K0852
K0853	K0854	K0855	K0856	K0857	K0858	K0859	K0860
K0861	K0862	K0863	K0864

Product Category 4-Mail-Order Diabetic Supplies (for the detailed product description of each HCPCS code/modifier see Attachment A)

HCPCS Codes/Modifiers
A4233 KL	A4234 KL	A4235 KL	A4236 KL	A4253 KL	A4256 KL
A4258 KL	A4259 KL

Product Category 5- Enteral Nutrients, Equipment, and Supplies (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Codes
B4034	B4035	B4036	B4081	B4082	B4083	B4087	B4088
B4149	B4150	B4152	B4153	B4154	B4155	B9000	B9002
E0776

Product Category 6- Continuous Positive Airway Pressure Devices, Respiratory Assist devices, and Related Supplies and Accessories (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Code
A4604	A7030	A7031	A7032	A7033	A7034	A7035	A7036
A7037	A7038	A7039	A7044	A7045	A7046	E0470	E0471
E0472	E0561	E0562

Product Category 7-Hospital Beds and Related Supplies (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Code
E0250	E0251	E0255	E0256	E0260	E0261	E0265	E0266
E0271	E0272	E0280	E0290	E0291	E0292	E0293	E0294
E0295	E0296	E0297	E0300	E0301	E0302	E0303	E0304
E0305	E0310	E0316	E0910	E0911	E0912	E0940

Product Category 8-Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Code
A6550	A7000	E2402

Product Category 9-Walkers and Related Supplies (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Code
A4636	A4637	E0130	E0135	E0140	E0141	E0143	E0144	E0147
E0148	E0149	E0154	E0155	E0156	E0157	E0158	E0159

Product Category 10-Support Surfaces (for the detailed product description of each HCPCS code see Attachment A)

HCPCS Code
E0193	E0277	E0371	E0372	E0373

Billing Instructions for Power Wheelchair Harness (HCPCS code E2313)

The April Quarterly Update for the 2007 DMEPOS Fee Schedule included instructions for suppliers to submit claims for the electronics necessary to upgrade from a non-expandable controller to an expandable controller at initial issue using HCPCS code E2399. This instruction was intended as a temporary measure until a new code could be added to describe the electronics/cables/junction boxes used when upgrading from a non-expandable controller at initial issue.

HCPCS code E2313 (Power Wheelchair Accessory, Harness For Upgrade to Expandable Controller, Including all Fasteners, Connectors and Mounting Hardware, Each) was added to the HCPCS effective January 1, 2008, for use in paying claims for the electronics furnished when upgrading from a non-expandable controller at initial issue.
Suppliers may submit claims for the electronics provided at initial issue using HCPCS code E2313 for dates of service on or after January 1, 2008, and must no longer use HCPCS code E2399 for submission of such items.
Claims submitted for the electronics necessary to upgrade from a non-expandable controller to an expandable controller using HCPCS code E2399 are invalid and will be denied as contractor/supplier responsibility. When such claims are denied, CMS will use message codes of M20 (Missing/incomplete/invalid HCPCS), 189 (Not otherwise classified or unlisted procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.), N211 (Alert: You may not appeal this decision.), and MA13 (You may be subject to penalties if you bill the patient for amount not reported with the PR (patient responsibility) group code.). These denials are made as CO-Contractual Obligation denials.

Additional Information

For complete details regarding this Change Request (CR) please see the official instruction (CR 6270) issued to your Medicare A/B MAC, DME/MAC, carrier, FI or RHHI. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1630CP.pdf (PDF, 103 KB).

If you have questions, please contact our Provider Contact Center at our toll free number (866) 332-7025.

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 2008 American Medical Association.

last updated on 12/05/2008

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