MLN Matters Number: MM6221
Related Change Request (CR) #: 6221
Related CR Release Date: October 3, 2008
Effective Date: January 1, 2009
Related CR Transmittal #: R1613CP
Implementation Date: January 5, 2009
Provider Types Affected
Physicians, providers, and suppliers billing Medicare contractors (carriers, Fiscal Intermediaries, (FIs), Medicare Administrative Contractors (MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs)) for splints, casts, dialysis equipment, and certain intraocular lenses.
What You Need to Know
CR 6221, from which this article is taken, instructs your carriers, FIs, MACs, and DME MACs how to calculate reasonable charges for the payment of claims for splints, casts, dialysis supplies, dialysis equipment, and intraocular lenses furnished in calendar year 2009. CR6221 also announces that the 2009 Inflation-Indexed Charge IIC update factor is 5.0 percent.
Background
Payment on a reasonable charge basis is required for splints, casts, dialysis supplies, dialysis equipment, and intraocular lenses by regulations contained in 42 CFR 405.501.
For calendar year 2009, Medicare will continue to pay for splints, casts, dialysis supplies, dialysis equipment and intraocular lenses on a reasonable charge basis.
In addition, please note that: 1) Payment for intraocular lenses is only made on a reasonable charge basis for lenses implanted in a physician’s office; and 2) You should use the Q-codes for splints and casts, when supplies are indicated for cast and splint purposes. This payment is in addition to the payment made under the Medicare physician fee schedule for the procedure for applying the splint or cast.
The 2009 payment limits for splints and casts will be based on the 2008 limits that were announced in CR 5740 last year, increased by 5.0 percent (the percentage change in the consumer price index for all urban consumers for the 12-month period ending June 30, 2008). (The MLN Matters article related to CR 5740 can be viewed at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5740.pdf (PDF, 119 KB).)
Change Request 6221 instructs your carrier or MAC to: 1) Compute 2009 customary and prevailing charges for the V2630, V2631, and V2632 (Intraocular Lenses Implanted in a Physician’s Office) using actual charge data from July 1, 2007, through June 30, 2008; and 2) Compute 2009 Inflation-Indexed Charge (IIC) amounts for these codes that were not paid using gap-filled payment amounts in 2008.
The 2009 Inflation-Indexed Charge IIC update factor is 5.0 percent.
For codes identified in the following four tables, CR 6221 instructs DME MACs to compute 2009 customary and prevailing charges using actual charge data from July 1, 2007 through June 30, 2008; and will compute 2009 IIC amounts for the codes that were not paid using gap-filled amounts in 2008.
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Table 1: Dialysis Supplies HCPCS Codes Billed with AX HCPCS Modifier
|
| A4215 |
A4216 |
A4217 |
A4244 |
A4245 |
A4246 |
A4247 |
A4248 |
|
A4450
|
A4452
|
A4651
|
A4652
|
A4657
|
A4660
|
A4663
|
A4670
|
|
A4927
|
A4928
|
A4930
|
A4931
|
A6216
|
A6250
|
A6260
|
A6402
|
|
Table 2: Dialysis Supplies HCPCS Codes Billed Without AX HCPCS Modifier
|
| A4653 |
A4671 |
A4672 |
A4673 |
A4674 |
A4680 |
A4690 |
A4706 |
A4707 |
|
A4708
|
A4709
|
A4714
|
A4719
|
A4720
|
A4721
|
A4722
|
A4723
|
A4724
|
|
A4725
|
A4726
|
A4728
|
A4730
|
A4736
|
A4737
|
A4740
|
A4750
|
A4755
|
|
A4760
|
A4765
|
A4766
|
A4770
|
A4771
|
A4772
|
A4773
|
A4774
|
A4802
|
|
A4860
|
A4870
|
A4890
|
A4911
|
A4918
|
A4929
|
E1634
|
|
|
|
Table 3: Dialysis Equipment HCPCS Codes/Modifier Billed with AX HCPCS Modifier
|
| E0210NU |
E1632 |
E1637 |
E1639 |
| Table 4: Dialysis Equipment HCPCS Codes Billed Without AX HCPCS Modifier |
| E1500 |
E1510 |
E1520 |
E1530 |
E1540 |
E1550 |
|
E1560
|
E1570
|
E1575
|
E1580
|
E1590
|
E1592
|
|
E1594
|
E1600
|
E1610
|
E1615
|
E1620
|
E1625
|
|
E1630
|
E1635
|
E1636
|
|
|
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Your contractors will make payment for splints and casts furnished in 2009 based on the lower of the actual charge or the payment limits established for these codes. They will use the 2009 reasonable charges or the attached 2009 splints and casts payment limits to pay claims for items furnished from January 1, 2009 through December 31, 2009. Please refer to Attachment A, at the end of this article for a detailed list of the applicable HCPCS codes and 2009 payment limits.
Additional Information
Detailed instructions for calculating:
- Reasonable charges are located in the Medicare Claims Processing Manual, Chapter 23 (Fee Schedule Administration and Coding Requirements), Section 80 (Reasonable Charges as Basis for Carrier/DMERC Payments)
- Customary and prevailing charges are located in Medicare Claims Processing Manual, Chapter 23 (Fee Schedule Administration and Coding Requirements), Sections 80.2 (Updating Customary and Prevailing Charges) and 80.4 (Prevailing Charge) and
- The IIC are located in Medicare Claims Processing Manual, Chapter 23 (Fee Schedule Administration and Coding Requirements), Sections 80.6 (Inflation Indexed Charge (IIC) for Nonphysician Services)
For complete details regarding this Change Request (CR) please see the official instruction (CR 6221) issued to your Medicare FI, carrier, MAC, or DME MAC. That instruction may be viewed by going to www.cms.hhs.gov/Transmittals/downloads/R1613CP.pdf (PDF, 178 KB).
If you have any questions, please contact our Provider Contact Center at our toll free number, (866) 332-7025 for Ohio/West Virginia or (888) 828-2092 for South Carolina.
Attachment A
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HCPCS Codes
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Payment Limit
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HCPCS Codes
|
Payment Limit
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|
A4565
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$7.75
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Q4025
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$34.07
|
|
Q4001
|
$44.11
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Q4026
|
$106.37
|
|
Q4002
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$166.75
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Q4027
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$17.04
|
|
Q4003
|
$31.69
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Q4028
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$53.19
|
|
Q4004
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$109.71
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Q4029
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$26.05
|
|
Q4005
|
$11.68
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Q4030
|
$68.58
|
|
Q4006
|
$26.33
|
Q4031
|
$13.03
|
|
Q4007
|
$5.86
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Q4032
|
$34.28
|
|
Q4008
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$13.17
|
Q4033
|
$24.30
|
|
Q4009
|
$7.80
|
Q4034
|
$60.44
|
|
Q4010
|
$17.56
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Q4035
|
$12.15
|
|
Q4011
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$3.90
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Q4036
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$30.23
|
|
Q4012
|
$8.78
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Q4037
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$14.83
|
|
Q4013
|
$14.20
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Q4038
|
$37.14
|
|
Q4014
|
$23.95
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Q4039
|
$7.43
|
|
Q4015
|
$7.10
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Q4040
|
$18.56
|
|
Q4016
|
$11.97
|
Q4041
|
$18.02
|
|
Q4017
|
$8.21
|
Q4042
|
$30.77
|
|
Q4018
|
$13.09
|
Q4043
|
$9.02
|
|
Q4019
|
$4.11
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Q4044
|
$15.39
|
|
Q4020
|
$6.55
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Q4045
|
$10.46
|
|
Q4021
|
$6.07
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Q4046
|
$16.83
|
|
Q4022
|
$10.96
|
Q4047
|
$5.22
|
|
Q4023
|
$3.06
|
Q4048
|
$8.42
|
|
Q4024
|
$5.48
|
Q4049
|
$1.91
|
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 2007 American Medical Association.