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Fee Schedule Update for 2006 for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
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MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers, including durable medical equipment regional carriers (DMERCs) and/or fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs), for services paid under the DMEPOS Fee Schedule
Provider Action Needed
This article is based on Change Request (CR) 4194, and provides specific information regarding the annual update for the 2006 DMEPOS Fee Schedule.
Background
The DMEPOS fee schedules are updated on a quarterly basis in order to:
- Implement fee schedule amounts for new codes; and
- Revise any fee schedule amounts for existing codes that were calculated in error.
Payment on a fee schedule basis is required for:
- Durable Medical Equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by the Social Security Act (Sections 1834(a)(h)(i)); and
- Parenteral and Enteral Nutrition (PEN) by regulations contained in the Code of Federal Regulations (42 CFR 414.102).
The 2006 DMEPOS Fee Schedule Update factors for Health Care Common Procedure Codes (HCPCS) items furnished from January 1, 2006, through December 31, 2006, and are as follows:
HCPCS Codes |
Notes |
A5120 |
Modifier “AV” is added for billing items furnished for facial prosthetics. Modifier “AU” is added for billing items furnished for urological supplies. |
L2005 |
Is being revised effective January 1, 2006, to ensure that the code’s allowable amount is representative of a full knee, ankle, foot orthoses (KAFO), including the joint component. |
L8609 and L8685 through L8689 |
Describe items that are subject to the fee schedule for prosthetics and orthotics ( PO) and are being added to the HCPCS effective January 1, 2006. These codes fall under the jurisdiction of the local carriers rather than the DMERCs. The Centers for Medicare & Medicaid Services (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 2006 HCPCS file as soon as it becomes available at http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage  on the CMS Web site. |
The following codes are being deleted from the HCPCS, effective January 1, 2006, and are therefore being removed from the DMEPOS and PEN fee schedule files:
A4254 A4643 thru A4647 A5119 A5509 A5511 B4184 B4186 E0169 E0752 E0754 thru E0759 E0953 E0954 E0972 E0996 E1000 E1001 E1019 E1021 E1025 thru E1027 E1210 thru E1213 E1239 K0064 K0066 K0067 K0068 K0074 K0075 K0076 K0078 K0102 K0104 K0106 K0415 K0416 K0452 K0600 K0618 thru K0620 K0628 thru K0649 K0670 K0671 K0731 K0732 L0860 L1750 L3963 L8100 L8110 L8120 L8130 L8140 L8150 L8160 L8170 L8180 L8190 L8195 L8200 L8230 L8239 L8620
The HCPCS codes listed below are being added to the HCPCS on January 1, 2006:
A4218 A4233 thru A4236 A4363 A4411 A4412 A4604 B4185 E0170 thru E0172 E0485 E0486 E0641 E0642 E2212 thru E2226 E2371 E2372 L0491 L0492 L0621 thru L0640 L3961 L3967 L3971 L3973 L3975 thru L3978 L5703 A5120 A5512 A5513 A6457 A6513 A6530 A6531 A6532 A6533 thru A6544 A6549 A9275 A9281 A9282 E0705 E0762 E0764 E0911 E0912 E1392 E1812 E2207 thru E2210 E2211 E2212 L0859 L2034 L2387 L3671 thru L3673 L3702 L3763 thru L3766 L3905 L3913 L3919 L3921 L3933 L3935 L5858 L5971 L6621 L6677 L6883 thru L6885 L7400 thru L7405 L7600 L8609 L8623 L8624 L8680 thru L8689
The Medicare DMERCs will gap-fill base fee schedule amounts for each state in their region for the following new HCPCS codes that will be subject to the DMEPOS fee schedules in 2006:
HCPCS Codes |
Notes |
A4363, A4411, A4412 |
Ostomy, Tracheostomy, or Urological Supplies (OS) |
A4233, A4234, A4235, A4236, A4604, E0485, E0486, E2216, E2217, E2218, E2222, E2223, E2225, E2226, E2371, E2372 |
Inexpensive or Routinely Purchased DME (IN) |
E0170, E0171, E0911, E0912, E1812 |
Capped Rental DME (CR) |
L0624, L0629, L0632, L0634, L2034, L2387, L3671, L3672, L3673, L3702, L3763, L3764, L3765, L3766, L3905, L3913, L3919, L3921, L3933, L3935, |
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L3961, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L5703, L5971, L6621, L6677, L6883, L6884, L6885, L7400, L7401, L7402, L7403, L7404, L7405 |
Prosthetics and Orthotics ( PO) |
A6513 |
Surgical Dressings (SD) |
Suppliers should remember to add HCPCS modifier AV when billing code A5120 for facial prosthetic items only when furnished in conjunction with a facial prosthesis. Also, add modifier AU when billing code A5120 for urological items only when furnished in conjunction with urological supplies.
Implementation
The implementation date for the instruction is January 3, 2006.
Additional Information
The official instruction issued to your carrier, intermediary, or DMERC regarding this change, can be found at http://cms.hhs.gov/transmittals/downloads/R770CP.pdf  on the CMS Web site. If you have questions regarding this issue, you may also contact your carrier, FI, or DMERC at their toll free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
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.
For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles .
Related Change Request (CR) #: 4194
Medlearn Matters Number: MM4194 Related CR Release Date: December 2, 2005
Effective Date: January 1, 2006 Related CR Transmittal #: 770
Implementation Date: January 3, 2006 Posted: 12/29/2005
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CPT codes, descriptions, and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
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