DME INFO

The 2017 Healthcare Common Procedure Coding System (HCPCS) File has been published. There are several additions, revisions, and discontinued HCPCS codes. The changes are effective January 1, 2017. Please keep in mind, the appearance of a HCPCS code is not an indication of coverage by the DME MAC.

The first listing contains the added HCPCS Codes that will take effect on January 01, 2017.  Please click on this link for more information.

DME MAC Joint Publication

Correct Healthcare Common Procedure Coding System (HCPCS) code selection for a product is an essential element for claims payment. Use of the appropriate HCPCS code assures that accurate processing can be accomplished resulting in a proper claim determination and reimbursement. Conversely, incorrect coding may result in improper payment necessitating recoupment and possible false claim actions. Thus, it is important that all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers take steps to ensure that claims are correctly coded.  Please see the entire article by clicking this link:  CORRECT CODING

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NEW Orthotic braces–reasonableness of Medicare payments compared to amounts paid by other payers

We will determine the reasonableness of Medicare fee schedule amounts for orthotic braces. We will compare Medicare payments made for orthotic braces to amounts paid by non-Medicare payers, such as private insurance companies, to identify potentially wasteful spending. We will estimate the financial impact on Medicare and on beneficiaries of aligning the fee schedule for orthotic braces with those of non-Medicare payers. (OAS; W-00-15-35756; expected issue date: FY 2016).

NEW Orthotic braces–supplier compliance with payment requirements

We will review Medicare Part B payments for orthotic braces to determine whether durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers’ claims were medically necessary and were supported in accordance with Medicare requirements. Prior OIG work indicated that some DMEPOS suppliers were billing for services that were medically unnecessary (e.g. beneficiaries receiving multiple braces and referring physician did not see the beneficiary) or were not documented in accordance with Medicare requirements. Medicare requires that such items be “reasonable and necessary.” (Social Security Act § 1862(a)(1)(A).) Further, LCDs issued by the four Medicare contractors that process DMEPOS claims include utilization guidelines and documentation requirements for orthotic braces. (OAS; W-00-15-35749; expected issue date: FY 2016).

For the entire 2016 Work Plan please click here:  2016 OIG Work Plan