The Centers for Medicare and Medicaid Services (CMS) has released the 2018 Medicare DMEPOS fee schedule which will be effective for Medicare claims with a date of service on or after January 1, 2018. The 2018 Medicare fee schedule for orthotic and prosthetic services will be increased by 1.1% over 2017 rates.
The 1.1% increase is a net reflection of the 1.6% increase in the Consumer Pricing Index for Urban Areas (CPI-U) from June 2016 through June 2017, combined with the annual Multi-Factor Productivity Adjustment (MFP) of -0.5%. The 1.1% increase in the O&P Medicare fee schedule for 2018 represents a 0.4% larger amount than the 2017 increase of 0.7%. Unfortunately, the 2% sequestration based reduction to all Medicare payments remains in effect (currently through 2025) meaning that Medicare fee for service payments will continue to be reduced by 2% due to sequestration. While sequestration continues to impact Medicare reimbursement, it is not cumulative. You will still receive 1.1% more for a service you provide in 2018 then you did in 2017 since the 2% sequestration reduction would be applied to both claims. Please click on the link to download the 2018 DMEPOS Fee Schedule https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
In the January 12, 2017 Federal Register (82 FR 3678), we published a proposed rule titled, “Medicare Program; Establishment of Special Payment Provisions and Requirements for Qualified Practitioners and Qualified Suppliers of Prosthetics and Custom Fabricated Orthotics” to ensure that only those who are qualified to do so can furnish, fabricate, and bill for the prosthetics and custom-fabricated orthotics addressed by the proposed rule.
We received over 5,000 public comments in response to the January 12, 2017 proposed rule.
In light of the cost and time burdens that the proposed rule would create for many providers and suppliers, particularly the cost and burden for those providers and suppliers that are small businesses, and the complexity of the issues raised in the detailed public comments received, we are withdrawing the January 12, 2017 proposed rule in order to assure agency flexibility in re-examining the issues and exploring options and alternatives with stakeholders.
Accordingly, the proposed rule published January 12, 2017, at 82 FR 3678, is withdrawn.
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The DME MAC Jurisdiction A has completed the widespread prepayment review of claims for Lumbar-Sacral Orthoses (HCPCS codes L0631 and L0637). These findings include claims processed primarily from March 2015 through May 2015. The review involved prepayment complex medical review of 1,384 claims submitted by 423 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 582 (42%) of the claims. For the remaining 802 claims, 148 claims were allowed and 654 claims were denied resulting in a claim denial rate of 82%. The overall CDR was 81.8%. Please click here for entire report
The Jurisdiction D, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code(s) L1832 and L1843. The quarterly edit effectiveness results from January 2015 through April 2015 are as follows:
The L1832 review involved 89 claims, of which 89 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100%.
The L1843 review involved 93 claims, of which 92 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 99%.
Top Denial Reasons
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Joint DME MAC Publication
This is a revision to a previously published article 3/28/2014.
As part of the 2014 and 2015 HCPCS update, codes were created describing certain OTS orthotics. Some of these codes parallel codes for custom fitted versions of the same items. Refer to the table at the end of this article for a listing of codes.
When providing these items suppliers must:
- Provide the product that is specified by the ordering physician
- Be sure that the ordering physician’s medical record justifies the need for the type of product (i.e., prefabricated versus custom fabricated)
- Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting
- Have detailed documentation in the supplier’s record that justifies the code selected
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