Category: Medicare

DMEPOS Competitive Bidding Program (CBP)

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The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) required

Medicare to replace the fee schedule payment methodology for selected DMEPOS items with a

competitive bidding program implemented in areas throughout the country. The DMEPOS CBP

helps Medicare establish sustainable prices, saves money for beneficiaries and taxpayers, and

limits fraud, waste, and abuse in the Medicare program. In addition to the cost savings, there

are several beneficiary protections that help to guarantee access to competitively bid DMEPOS

including requiring contract suppliers to provide equal access to all DMEPOS items and

services included in the supplier contract to every beneficiary residing in the competitive bidding

area.  Please click this link and go to page 21 for more information. CMS Competitive Bidding

New HCPCS Updates

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October 2024 HCPCS Updates – New, Revised, and Discontinued HCPCS Codes and Modifiers

The following information is based on the October 2024 Healthcare Common Procedure Coding System (HCPCS) file. There are updates that will be effective October 1, 2024. It’s important to remember that the appearance of a HCPCS code is not an indication of coverage by the DME MAC.

Please click here for the HCPCS codes that will be effective October 1, 2024.

Providing Orthoses Prior to Surgery – Reminder

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CGS wants to remind suppliers and providers that orthotic devices are not covered if they do not meet the coverage criteria outlined in the Local Coverage Determinations (LCDs) for the HCPCS code prescribed at the time of service.

Devices provided prior to the start of medical necessity (for example, before the surgery), will not meet the coverage criteria. After surgery, if there is documentation of the medical necessity for the orthotic device(s), you can provide the item, keeping in mind there are many other payment rules related to the claim.

For orthotic devices that require Prior Authorization (PA) (L0648, L0450, L1832, L1833, and L1851), do not submit PA requests prior to the start of medical necessity (for example, before the surgery). After surgery, if the medical record documentation shows an emergent need for the device(s), you can submit an expedited request. If an expedited request is not feasible, append the ST modifier to the claim to bypass PA. Claims submitted with the ST modifier are subject to 100% prepayment review.

Please click here for more information

DME MAC Jurisdiction B News from CGS

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CGS Medical Review Quarterly Reports by Policy

Analysis of claim denials for knee orthoses HCPCS codes L1833 and L1851 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 65.52%. Please click here for the top 10 reasons for claim denials.

Analysis of claim denials for AFO HCPCS codes L1902, L1906, L1971, L4396, and L4397 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 30.79%. Please click here for the top 10 reasons for claim denials.

Analysis of claim denials for lumbar sacral orthosis (LSO)HCPCS codes L0457, L0637, L0648, and L0650 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 38.37%. Please click here for the top 10 reasons for claim denials.

Analysis of claim denials for therapeutic shoes/inserts for diabetic persons HCPCS codes A5500 and A5512-A5514 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 88.35%. Please click here for the top 10 reasons for claim denials.

 

Please click the links below for additional policy information.

Medicare Announces Rule to Protect Consumers from Surprise Medical Bills

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Announcement is the first in a series of regulations aimed at shielding patients from increased financial hardships stemming from surprise medical bills

The Biden-Harris Administration, through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management, issued “Requirements Related to Surprise Billing; Part I,” an interim final rule that will restrict excessive out of pocket costs to consumers from surprise billing and balance billing. Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.

Please click on these links for more information   Consumer Protection  / What you need to know