Palmetto GBA - Ohio Part B Carrier - Reasonable Charge Update for 2010 for Splints, Casts, Dialysis Supplies, Dialysis Equipment, and Certain Intraocular Lenses

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Reasonable Charge Update for 2010 for Splints, Casts, Dialysis Supplies, Dialysis Equipment, and Certain Intraocular Lenses

MLN Matters® Number: MM6691

Related Change Request (CR) #: 6691

Related CR Release Date: October 23, 2009

Effective Date: January 1, 2010

Related CR Transmittal #: R1834CP

Implementation Date: January 4, 2010

Provider Types Affected

Physicians, providers, and suppliers, billing Medicare contractors (Carriers, Fiscal Intermediaries, (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs)) for splints, casts, dialysis supplies, dialysis equipment, and certain intraocular lenses, should be aware of this article.

Provider Action Needed

The 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.

CR 6691, 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 2010. Make sure your billing staff is aware of these changes.

Background

CR 6691 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 2010.

The inflation indexed charge (IIC) is calculated using the lowest of the reasonable charge screens from the previous year updated by an inflation adjustment factor or the percentage change in the consumer price index for all urban consumers (CPI-U)(United States city average) for the 12-month period ending with June of 2009.

Since the percentage change in the CPI-U for the 12-month period ending with June of 2009 is negative (-1.41 percent), the IIC update factor for 2010 is 0 percent. The 2010 payment limits for splints and casts will be based on the 2009 limits that were announced in CR 6221 last year. Those limits are repeated in Attachment A at the end of this article. 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) The Q-codes should be used 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. An attachment to CR 6691 lists the 2010 Payment Limits for Splints and Casts.

CR 6691 instructs your carrier or MAC to: 1) Compute 2010 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, 2008, through June 30, 2009; and 2) Compute 2010 IIC amounts for these codes that were not paid using gap-filled payment amounts in 2009.

For codes identified in the following four tables, CR6691 instructs DME MACs to compute 2010 customary and prevailing charges using actual charge data from July 1, 2008 through June 30, 2009; and to compute 2010 IIC amounts for these codes that were not paid using gap-filled amounts in 2009.

Table 1

Dialysis Supplies Billed With AX HCPCS Modifier
A4215	A4244	A4247	A4452	A4657	A4670	A4930	A6250
A4216	A4245	A4248	A4651	A4660	A4927	A4931	A6260
A4217	A4246	A4450	A4652	A4663	A4928	A6216	A6402

Table 2

Dialysis Supplies Billed Without AX HCPCS Modifier
A4653	A4680	A4709	A4722	A4728	A4750	A4770	A4802	A4918
A4671	A4690	A4714	A4723	A4730	A4755	A4771	A4860	A4929
A4672	A4706	A4719	A4724	A4736	A4760	A4772	A4870	E1634
A4673	A4707	A4720	A4725	A4737	A4765	A4773	A4890
A4674	A4708	A4721	A4726	A4740	A4766	A4774	A4911

Table 3

Dialysis Equipment Billed With AX HCPCS Modifier
E0210NU	E1632	E1637	E1639

Table 4

Dialysis Equipment Billed Without AX HCPCS Modifier
E1500	E1540	E1575	E1594	E1620	E1636
E1510	E1550	E1580	E1600	E1625
E1520	E1560	E1590	E1610	E1630
E1530	E1570	E1592	E1615	E1635

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).

The Medicare Claims Processing Manual is available at

http://www.cms.hhs.gov/manuals/IOM/list.asp on the Centers for Medicare & Medicaid Services (CMS) website.

For complete details regarding this Change Request (CR) please see the official instruction (CR 6691) issued to your Medicare FI, Carrier, MAC, or DME MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1834CP.pdf on the CMS website.

If you have any questions, please contact the Palmetto Provider Contact Center at our toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).

Attachment A

HCPCS Code	Payment Limit	HCPCS Code	Payment Limit
A4565	$7.75	Q4025	$34.07
Q4001	$44.11	Q4026	$106.37
Q4002	$166.75	Q4027	$17.04
Q4003	$31.69	Q4028	$53.19
Q4004	$109.71	Q4029	$26.05
Q4005	$11.68	Q4030	$68.58
Q4006	$26.33	Q4031	$13.03
Q4007	$5.86	Q4032	$34.28
Q4008	$13.17	Q4033	$24.30
Q4009	$7.80	Q4034	$60.44
Q4010	$17.56	Q4035	$12.15
Q4011	$3.90	Q4036	$30.23
Q4012	$8.78	Q4037	$14.83
Q4013	$14.20	Q4038	$37.14
Q4014	$23.95	Q4039	$7.43
Q4015	$7.10	Q4040	$18.56
Q4016	$11.97	Q4041	$18.02
Q4017	$8.21	Q4042	$30.77
Q4018	$13.09	Q4043	$9.02
Q4019	$4.11	Q4044	$15.39
Q4020	$6.55	Q4045	$10.46
Q4021	$6.07	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 2008 American Medical Association.

last updated on 10/30/2009