The latest in DME news, from regulations and guidelines to payer and patient trends.
CMS released a Final Rule for the DMEPOS Competitive Bid Program and Fee Schedule amounts on November 1. Attached to the End-Stage Renal Disease update, the Final Rule addresses many reimbursement challenges that surround the competitive bidding program. Find the Final Rule here . Summary of main points in the Final Rule.
Competitive Bidding will use Lead Item Pricing. Lead Item Pricing takes one lead item from the Competitive Bid Product Category on which the supplier must bid. The single payment amount will be created based on the highest winning bid. The rest of the items in that Competitive Bid Product Category will be priced based on a percentage of the highest winning bid of the lead item compared to the 2015 fee schedule.
Gap Period Rate methodology was released. For Rural and non-contiguous non-competitive bid areas, the rate is based on a blended 50 /50 rate of the unadjusted fee schedule and the adjusted fee schedule for all other areas. For non-rural areas, the rate will still be the adjusted rate. For competitive bid areas, the rate will continue to be the single payment amount (SPA) for 12 months. Then every 12 months there is no competitive bid program, the rate will increase at the same rate of the consumer price index for all urban consumers. The rate will go into effect on January 1 of each year there is no competitive bid.
New oxygen classes were added. Previously five oxygen classes encompassed the reimbursement rates for home oxygen. The Final Rule proposes seven classes, adding a special class for portable liquid oxygen, and portable liquid contents with more than 4 lpm prescribed. See chart from the final rule on pricing and the new classes.
Payment methodology for Multifunctioning Ventilators was added. A multifunction ventilator was approved by the FDA, but the capabilities of the machine include individual items across different fee schedule categories. As a result CMS determined a payment methodology where regardless of what features the patient is using of the multifunction ventilator, there is one flat rate reimbursement. It will be a frequently serviced item. Payments for the items that can be accomplished with this machine, such as oxygen, nebulizers, suction machines, and cough stimulation devices will denied. However, if the patient is only using the multifunction ventilator as a ventilator, the reimbursement should follow the standard E0465 or E0466 reimbursement.
National Mail Order Competitive Bid was extended to include the Northern Mariana Islands.
For additional information about the final rule and the gap period information, please see the contractor websites.
Healthcare Updates
Upcoming events and news to keep you ahead of the curve.
Effective January 1, 2019, all competitive bid contracts will be expired. For providers, this means that any Medicare enrolled provider can provide services to patients. This also means that previously restricted Competitive bid contract awardees can bill competitive bid items non-assigned to patients residing in a CBA. To find out more information on the gap period, see the flyer released by CMS here.
Best Practices
Do’s and don’t’s developed to maximize returns and minimize denials.
October 1 of every year CMS releases updates to the International Classification of Disease (ICD) codes. Please be sure to check your claim rejections to ensure the diagnosis codes on rentals are still valid codes for the ICD-10 version. The most common change is where a code is more specified and therefore the code previously acceptable as a billing code may no longer be acceptable.
