Reasonable Charge Update for 2008 Splints, Casts, Dialysis Supplies, Dialysis Equipment & Certain Intraocular Lenses
MLN Matters Number: MM5740 Revised
Related Change Request (CR) #: 5740
Related CR Release Date: September 28, 2007
Effective Date: January 1, 2008
Related CR Transmittal #: R1344CP
Implementation Date: January 7, 2008
Note: This article was revised on November 7, 2007 to change the title to the chart showing the payment limits. That chart should have read 2008 and not 2007. All other information is unchanged.
Provider Action Needed
Affected providers may want to be certain their billing staffs know of these changes.
Background
For calendar year 2008, Medicare will continue to pay on a reasonable charge basis for splints, casts, dialysis supplies, dialysis equipment and intraocular lenses. For intraocular lenses, payment is only made on a reasonable charge basis for lenses implanted in a physician’s office. For splints and casts, the Q HCPCS codes are to be used 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.
Change Request (CR) 5740 provides instructions regarding the calculation of reasonable charges for payment of claims for splints, casts, dialysis supplies, dialysis equipment, and intraocular lenses furnished in calendar year 2008. Payment on a reasonable charge basis is required for these items by regulations contained in 42 CFR 405.501 at www.gpoaccess.gov/cfr/retrieve.html. The 2008 payment limits for splints and casts will be based on the 2007 limits that were announced in CR 5382 last year, increased by 2.7 percent, the percentage change in the consumer price index for all urban consumers for the 12-month period ending June 30, 2007. The MLN Matters article related to CR 5382 can be viewed at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5382.pdf (PDF, 108 KB).
For intraocular lenses, payment is made only on a reasonable charge basis for lenses implanted in a physician’s office. CR 5740 instructs your carrier, or A/B MAC to compute 2008 customary and prevailing charges for HCPCS codes V2630, V2631, and V2632 (Intraocular Lenses Implanted in a Physician’s Office) using actual charge data from July 1, 2006, through June 30, 2007.
Carriers and A/B MACs will compute 2008 Inflation-Indexed Charge (IIC) amounts for HCPCS codes V2630, V2631, and V2632 that were not paid using gap-filled payment amounts in 2007.
DME MACs will compute 2008 customary and prevailing charges for the codes identified in the following tables using actual charge data from July 1, 2006, through June 30, 2007. For these same codes, they will compute 2008 IIC amounts for the codes identified in the following tables that were not paid using gap-filled amounts in 2007. These tables are:
|
Dialysis Supplies HCPCS Codes Billed with AX HCPCS Modifier
|
| A4216 |
A4217 |
A4248 |
A4244 |
A4245 |
A4246 |
|
A4247
|
A4450
|
A4452
|
A6250
|
A6260
|
A4651
|
|
A4652
|
A4657
|
A4660
|
A4663
|
A4670
|
A4927
|
|
A4928
|
A4930
|
A4931
|
A6216
|
A6402
|
|
|
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
|
|
|
|
|
|
|
Dialysis Equipment HCPCS Codes Billed With AX HCPCS Modifier
|
| E0210NU |
E1632 |
E1637 |
E1639 |
|
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
|
|
|
|
Palmetto GBA will make payment for splints and casts furnished in 2008 based on the lower of the actual charge or the payment limits established for these codes. Contractors will use the 2008 reasonable charges or the attached 2008 splints and casts payment limits to pay claims for items furnished from January 1, 2008 through December 31, 2008. Those 2008 payment limits are at the end of this article.
Additional Information
Detailed instructions for calculating:
- Reasonable charges are located in Chapter 23 (Section 80) of the Medicare Claims Processing Manual
- Customary and prevailing charge are located in Section 80.2 and 80.4 of Chapter 23 of the Medicare Claims Processing Manual and
- The IIC (Inflation Indexed Charge) are located in Section 80.6 of Chapter 23 of the Medicare Claims Processing Manual. The IIC update factor for 2008 is 2.7 percent
If you have questions, please contact us at (866) 332-7025 for Ohio/West Virginia or (888) 828-2092 for South Carolina.
2008 Payment Limits for Splints & Casts
|
HCPCS Code
|
Payment Limit
|
HCPCS Code
|
Payment Limit
|
|
A4565
|
$7.38
|
Q4025
|
$32.45
|
|
Q4001
|
$42.01
|
Q4026
|
$101.30
|
|
Q4002
|
$158.81
|
Q4027
|
$16.23
|
|
Q4003
|
$30.18
|
Q4028
|
$50.66
|
|
Q4004
|
$104.49
|
Q4029
|
$24.81
|
|
Q4005
|
$11.12
|
Q4030
|
$65.31
|
|
Q4006
|
$25.08
|
Q4031
|
$12.41
|
|
Q4007
|
$5.58
|
Q4032
|
$32.65
|
|
Q4008
|
$12.54
|
Q4033
|
$23.14
|
|
Q4009
|
$7.43
|
Q4034
|
$57.56
|
|
Q4010
|
$16.72
|
Q4035
|
$11.57
|
|
Q4011
|
$3.71
|
Q4036
|
$28.79
|
|
Q4012
|
$8.36
|
Q4037
|
$14.12
|
|
Q4013
|
$13.52
|
Q4038
|
$35.37
|
|
Q4014
|
$22.81
|
Q4039
|
$7.08
|
|
Q4015
|
$6.76
|
Q4040
|
$17.68
|
|
Q4016
|
$11.40
|
Q4041
|
$17.16
|
|
Q4017
|
$7.82
|
Q4042
|
$29.30
|
|
Q4018
|
$12.47
|
Q4043
|
$8.59
|
|
Q4019
|
$3.91
|
Q4044
|
$14.66
|
|
Q4020
|
$6.24
|
Q4045
|
$9.96
|
|
Q4021
|
$5.78
|
Q4046
|
$16.03
|
|
Q4022
|
$10.44
|
Q4047
|
$4.97
|
|
Q4023
|
$2.91
|
Q4048
|
$8.02
|
|
Q4024
|
$5.22
|
Q4049
|
$1.82
|