Provider Notice: 05-207
Medlearn Matters Number: MM4194
Original Issue Date: December 30, 2005
FROM: Medicare Communications
SUBJECT: Fee Schedule Update for 2006 for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. Additional copies may be downloaded from our website at www.highmarkmedicareservices.com
Coming in 2006! Beginning January 1, 2006, Medicare prescription drug coverage will be available to people with Medicare. Health care professionals can find information about this new coverage at www.cms.hhs.gov/medlearn/drugcoverage.asp, on the CMS website.
Announcing the new CMS web page dedicated to providing all the latest NPI news for Fee-For-Service (FFS) Medicare providers! Visit http://www.cms.hhs.gov/NationalProvIdentStand/ on the web! While this page is dedicated to the Medicare FFS community, it contains helpful information and links that may benefit all health care providers.
Reminder--Health care providers are required by law to apply for a National Provider Identifier (NPI).To apply online, visit: https://nppes.cms.hhs.gov
Related Change Request (CR) #: 4194
Related CR Release Date: December 2, 2005
Related CR Transmittal #: 770
Effective Date: January 1, 2006
Implementation Date: January 3, 2006
Providers Type 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
Providers Action Needed:
This article is based on Change Request (CR) 4194, and it 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).
Note: DMERCs will use the 2006 PEN fee schedule payment amounts to payclaims for items furnished from January 1, 2006 through December 31, 2006.
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 codes allowable amount is representative of a full knee, ankle, foot orthosis (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 gapfilling 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 A5120 A5512 A5513 A6457 A6513 A6530 A6531 A6532 A6533 thru A6544 A6549 A9275 A9281 A9282 | B4185 E0170 thru E0172 E0485 E0486 E0641 E0642 E0705 E0762 E0764 E0911 E0912 E1392 E1812 E2207 thru E2210 E2211 E2212 | E2212 thru E2226 E2371 E2372 L0491 L0492 L0621 thru L0640 L0859 L2034 L2387 L3671 thru L3673 L3702 L3763 thru L3766 L3905 L3913 L3919 L3921 L3933 L3935 | L3961 L3967 L3971 L3973 L3975 thru L3978 L5703 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, 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://www.cms.hhs.gov/transmittals/downloads/R770CP.pdf on the CMS web site.
Assistance:
If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:
Maryland Providers: 1-866-488-0545
Pennsylvania Providers: 1-800-560-6170