MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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MMA - Fee
Schedule Update for 2005 for Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies
(DMEPOS)
Provider Types Affected
Physicians, providers, and suppliers
Provider Action Needed
This
instruction provides specific information regarding the
2005 annual update for the DMEPOS fee schedule.
Background
The DMEPOS fee schedules are updated on an annual
basis in accordance with the statute and regulations, as
described in the Medicare Claims Processing Manual (Pub
100-04, Section 60, Chapter 23).
This notification provides details regarding the 2005
annual update for the DMEPOS fee schedule.
The Social Security Act (SSA) (Sections 1834(a), (h),
and (i)) requires payment on a fee schedule basis for
durable medical equipment (DME), prosthetic devices,
orthotics, prosthetics, and surgical dressings. In
addition, the Code of Federal Regulations (42 CFR
414.102) requires payment on a fee schedule basis for
Parenteral and Enteral Nutrition (PEN).
The 2005 DMEPOS fee schedule update factors for items
furnished from January 1, 2005 through
December 31, 2005 are as follows:
- DME other than items classified as class III
devices by the Food and Drug Administration (FDA)
– 0 percent
- DME classified as class III devices by the FDA
– 3.3 percent
- Prosthetic devices, prosthetics, and orthotics
– 0 percent
- PEN – 3.3 percent
- Surgical dressings – 0 percent
Please refer to the table below for comments and notes
on several Healthcare Common Procedure Coding System
(HCPCS) codes. The descriptions for the items falling
under the HCPCS codes listed in the table can be obtained
from the HCPCS file at https://www.cms.hhs.gov/medicare/hcpcs/default.asp
Healthcare Common Procedure
Coding System Codes
| HCPCS Codes |
Notes |
| A4253, A4259,
E0260, E0277, E0424, E0431, E0434, E0439, E0570,
E1390, E1391, K0001, and K0011 |
These codes are affected
by the provision in Section 302 (c)(2) of the
Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) requiring reductions
for certain DME equal to the percentage difference
between 2002 Medicare fee schedule amounts and the
median 2002 price paid under Federal Employee Health
Benefit (FEHB) plans surveyed by the Office of the
Inspector General. The reductions take effect January
1, 2005, and will be implemented as part of this
annual update to the DMEPOS fee schedules. |
A5500
(extra-depth shoe)
A5501 (custom molded shoe)
K0628 (direct formed insert)
K0629 (custom molded insert) |
Section 627 of the MMA
requires the calculation and implementation of fee
schedule amounts for therapeutic shoes and inserts
effective January 1, 2005. Fee schedules for these
HCPCS codes have been calculated by CMS using the
methodology contained in section 1834(h) of the
Social Security Act for prosthetic devices,
prosthetics, and orthotics. These fee schedule
amounts will be implemented as part of this annual
update to the DMEPOS fee schedules. |
A5503 thru A5507
(shoe modification codes)
K0628 or K0629 (inserts) |
In accordance with
section 1833(o)(2)(C) of the Social Security Act, the
payment amounts established for shoe modification
codes (A5503 thru A5507) must be established in a way
that prevents a net increase in expenditures when
substituting these items for inserts (codes K0628 or
K0629). Therefore, the 2005 fee schedule amounts for
codes A5503 thru A5507 have been calculated based on
the weighted average of the fee schedule amounts for
insert codes K0628 and K0629. The fees for K0628 and
K0629 were weighted based on the approximate total
allowed services for each code for items furnished
during the second quarter of calendar year 2004. For
2006 and each subsequent year, the weighted average
insert fee used to establish the fee schedule amounts
for the shoe modification codes will be based on an
updated weighted average (i.e., using more current
allowed service data for each insert code). |
|
E0675 |
Code E0675 was added to
the HCPCS effective January 1, 2004. The fee schedule
for code E0675 was calculated using retail prices for
two products; however, the fee schedule is being
revised effective January 1, 2005, to remove pricing
for one product that was not yet an established
product in the market at the time the code was
added. |
|
E1010 |
The description for code
E1010 for "wheelchair accessory, addition to
power seating system, including leg rest,
…each" is changed
effective January 1, 2005, to show "wheelchair
accessory, addition to power seating
system,……., including leg rest,
pair" and the fee schedule for
E1010 is revised to reflect this change. Suppliers
should bill single leg rest power elevation systems
under code K0108. |
| E2320 thru
E2330, and Modifier KC |
Codes E2320 thru E2330
for special power wheelchair interfaces were added to
the HCPCS effective January 1, 2004. The fee schedule
amounts for these codes were calculated based on
pricing for the differential cost of furnishing these
special interfaces over a standard interface that is
paid for as part of the payment for the wheelchair
(e.g., K0011). However, when these items are
furnished to replace existing interfaces on
wheelchairs that have been in use by the patient for
a period of time due to a change in the
patient’s medical condition or in cases where
the existing interface is irreparably damaged or has
exceeded its reasonable useful lifetime, the fee
schedule payment should reflect payment for the full
cost of the replacement special interface. Modifier
KC is being added to the HCPCS effective January 1,
2005, to identify replacement of special power
wheelchair interfaces in these cases. Fee schedule
amounts for replacement of special power wheelchair
interfaces will be established effective January 1,
2005, for use in paying claims for use Codes E2320
thru E2330 billed with the KC modifier. |
| E2340 thru
E2343, and K0108 |
Codes E2340 thru E2343
for nonstandard power wheelchair seat frame width and
depth were added to the HCPCS effective January 1,
2004. The fee schedule amounts for these codes were
calculated using retail prices for some products for
nonstandard seat dimensions (i.e., captain’s
chairs that sit on top of power wheelchair bases) as
opposed to nonstandard seat frame dimensions. The
base fee schedule amounts for codes E2340 thru E2343
will be adjusted to remove these products from the
base fee calculations. Suppliers of nonstandard seat
dimensions should bill HCPCS K0108 instead of codes
E2340 thru E2343. |
| K0646, K0648,
and L0565 |
The fee schedule amounts
for codes K0646 and K0648 are being revised effective
January 1, 2005, by crosswalking the fee schedule
amounts for previous code L0565 to both code K0646
and K0648. As a result of a court settlement,
previously paid claims for K0646 and K0648 that were
submitted between July 6, 2004 and January 1, 2005,
shall be adjusted if such claims are resubmitted by
suppliers on or after January 1, 2005, and on or
before 18 months after the date the claim was
originally submitted. |
| E0617, E0691
thru E0694, K0606 thru K0609, and modifier
KF |
A one-time notification
(Transmittal 35, Change Request 3020) was issued on
December 24, 2003, and listed HCPCS codes for
categories of DME items identified by the FDA as
class III devices. As indicated above, the fee
schedule amounts for class III DME will be increased
by 3.3 percent effective January 1, 2005, whereas the
fee schedule amounts for items that are not
classified as class III devices by the FDA will not
be increased on January 1, 2005. Transmittal 35
indicated that HCPCS codes E0617, E0691 thru E0694,
and K0606 thru K0609 represented codes for categories
of DME items identified by the FDA as class III
devices. However, some products billed under these
codes are not class III devices. Therefore, effective
January 1, 2005, separate fee schedules will be
provided in the DMEPOS fee schedule file: one for
class III products within these codes that must be
billed with HCPCS modifier KF and one for products
within these codes that are not class III devices
that may not be billed with HCPCS modifier KF. |
| A7040, A7041,
L8615 thru L8618, L8620 thru L8622 |
Codes A7040, A7041, L8615 thru L8618, and
L8620 thru L8622 describe items that are subject to
the fee schedule for prosthetics and orthotics (PO)
and are being added to the HCPCS effective January
1, 2005. These codes fall under the jurisdiction of
the local carriers rather than the DMERCs. CMS will
be calculating the fee schedule amounts for these
items using the standard gap-filling process. The
description for these codes can be obtained from
the 2005 HCPCS file as soon as it is available
at:
http://www.cms.hhs.gov/medicare/hcpcs/default.asp
|
| A4324 thru
A4325; A4347; A4609 thru A4610; B4151; B4156; E0176
thru E0179; E0192; E0454; E0962 thru E0965; E1012
thru E1013; K0023 thru K0024; K0059 thru K0061;
K0081; K0114 thru K0116; K0627; L0476; L0478; L0500;
L0510; L0515; L0520; L0530; L0540; L0550; L0560 thru
L0561; L0565* L0600; L0610; L0620; L2435; L5674 thru
L5675; L5846 thru L5847; L5989; L8490 |
These codes are being deleted from the HCPCS
effective January 1, 2005, and are therefore being
removed from the DMEPOS and PEN fee schedule
files.
*As indicated above, the fee schedule amounts
for code L0565 are being crosswalked to codes K0646
and K0648.
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Additional Information
The official instruction issued to your carrier,
intermediary, or DMERC regarding this change, can be
found at:
http://www.cms.hhs.gov/Transmittals/
On the above page, scroll down while referring to the
CR NUM column on the right to find the link for CR 3574.
Click on the link to open and view the file for the
CR.
If you have questions regarding this issue, you may
also contact your carrier, fiscal intermediary, or
DMERC at their toll free number, which may be found
at:
http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf
Disclaimer
Medlearn Matters articles are prepared as a service to
the public and are not intended to grant rights or impose
obligations. Medlearn Matters articles 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.
Related Change Request (CR) #: 3574
Medlearn Matters Number: MM3574
Related CR Release Date: November 19,
2004
Related CR Transmittal #: 369
Effective Date: January 1, 2005
Implementation Date: January 3, 2005
Posted: 12/07/2004
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