Change Request 6566 Provides Guidance on Implementing Edits for Certain DMEPOS Items

Transmittal 625, dated January 25, 2010, is being rescinded and replaced by Transmittal 669 to clarify the Remittance Advice Remark Code and the Claim Adjustment Reason Code to be used by DME MACs for claims processing denials as a result of this instruction. In addition, the 'Supporting Information,' in part IV was revised to delete the editing requirement of 'Miami Only' in the Support Surfaces category in Attachment C, per contractor request. All other information remains the same.

Section 302 of the Medicare Modernization Act of 2003 added a new paragraph to the Social Security Act (the Act), section 1834(a)(20), requiring the Secretary to establish and implement quality standards for suppliers of DMEPOS. All suppliers that furnish such items or services required in the new paragraph, as the Secretary determines appropriate, must comply with the quality standards in order to receive Medicare Part B payments and to retain a supplier billing number. The covered items and services are defined in the Act. The Medicare Improvements for Patients and Providers Act of 2008 added a new subparagraph for implementing quality standards which state the Secretary shall require suppliers furnishing items and services on or after October 1, 2009, directly or as a subcontractor for another entity, to have submitted evidence of accreditation by an accreditation organization designated by the Secretary.

The Centers for Medicare & Medicaid Services (CMS) is issuing CR6566 to provide further guidance to suppliers of DMEPOS regarding licensing, accreditation or other mandatory quality requirements that may apply. DMEPOS suppliers should be aware that if they are not identified by the National Supplier Clearinghouse-Medicare Administrative Contractor (NSC-MAC) as being accredited to supply the specific product/service and they are not exempt from accreditation, their claims will be automatically denied by Medicare. Edits for the Healthcare Common Procedure Coding System (HCPCS) codes in the product categories designated by MIPPA as requiring accreditation will be in effect for claims with dates of service on or after July 6, 2010.

The eligible professionals who are exempt from meeting accreditation requirement (as defined in Section 1848(k)(3)(B)) include the following practitioners:

• Physicians (as defined in Section 1861(r) of the Act)
• Physical Therapists
• Occupational Therapists
• Qualified Speech-Language Pathologists
• Physician Assistants
• Nurse Practitioners
• Clinical Nurse Specialists
• Certified Registered Nurse Anesthetists
• Certified Nurse-Midwives
• Clinical Social Workers
• Clinical Psychologists
• Registered Dietitians
• Nutritional Professionals

Additionally, MIPPA allows that 'other persons' are exempt from meeting the accreditation deadline unless CMS determines that the quality standards are specifically designed to apply to such other persons. At this time, 'such other persons' are specifically defined as the following practitioners:

• Orthotists
• Prosthetists
• Opticians
• Audiologists

View the MLN Matters Article 6566 in its entirety.