(Medicare Claims Processing Manual)

Examples of Attributes in Each Component Category   Physical: Aesthetics, Design, Customized vs. Standard, Material, Portable, Size, Temperature Range/Tolerance, Weight    Mechanical:  Automated vs. Manual, Brittleness, Ductility, Durability, Elasticity, Fatigue, Flexibility, Hardness, Load Capacity, Flow -Control, Permeability, Strength   Electrical:  Capacitance, Conductivity, Dielectric Constant, Frequency, Generator, Impedance, Piezo -electric, Power, Power Source, Resistance    Function and Intended Use:  Function, Intended Use    Additional Attributes and Features: Smart, Alarms, Constraints, Device Limitations, Disposable, Parts, Features, Invasive vs. Non- Invasive.   If unable to identify comparable item(s), other sources of pricing data can be used to calculate the gap -filled fee schedule amount for the new item. These sources include using supplier or commercial price lists with prices in effect during the fee schedule data base year.  Data base year refers to the time period mandated by the statute and/or regulations from which Medicare allowed charge data is to be extracted in order to compute the fee schedule amounts for the various DMEPOS payment categories. For  example, the fee schedule base year for inexpensive or routinely purchased durable medical equipment is the 12 month period ending June 30, 1987. Supplier price lists include catalogues and other retail price lists (such as internet retail prices) that pr ovide information on commercial pricing for the item. Potential appropriate sources for such commercial pricing information can also include payments made by Medicare Advantage plans as well as verifiable information from supplier invoices and non- Medicare payer data. DME MACs and A/B MACs shall gap- fill based on current instructions released each year for implementing and updating the payment amounts.  If the only available price information is from a period other than the base period, apply the deflation factors that are included in the current year implementation instructions against current pricing in order to approximate the base year price for gap- filling purposes.   The deflation factors for gap -filling purposes are:   Year*  OX CR PO SD PE SC IL 1987  0.965  0.971  0.974  n/a n/a n/a n/a 1988  0.928  0.934  0.936  n/a n/a n/a n/a 1989  0.882  0.888  0.890  n/a n/a n/a n/a 1990  0.843  0.848  0.851  n/a n/a n/a n/a 1991  0.805  0.810  0.813  n/a n/a n/a n/a 1992  0.781  0.786  0.788  n/a n/a n/a n/a 1993  0.758  0.763  0.765  0.971  n/a n/a n/a 1994  0.740  0.745  0.747  0.947  n/a n/a n/a 1995  0.718  0.723  0.725  0.919  n/a n/a n/a 1996  0.699  0.703  0.705  0.895  0.973  n/a n/a 1997  0.683  0.687  0.689  0.875  0.951  n/a n/a 1998  0.672  0.676  0.678  0.860  0.936  n/a n/a 1999  0.659  0.663  0.665  0.844  0.918  n/a n/a 2000  0.635  0.639  0.641  0.813  0.885  n/a n/a 2001  0.615  0.619  0.621  0.788  0.857  n/a n/a 2002  0.609  0.613  0.614  0.779  0.848  n/a n/a 2003  0.596  0.600  0.602  0.763  0.830  n/a n/a 2004  0.577  0.581  0.582  0.739  0.804  n/a n/a 2005  0.563  0.567  0.568  0.721  0.784  n/a n/a 2006  0.540  0.543  0.545  0.691  0.752  n/a n/a 2007  0.525  0.529  0.530  0.673  0.732  n/a n/a 2008  0.500  0.504  0.505  0.641  0.697  n/a n/a 2009  0.508  0.511  0.512  0.650  0.707  n/a n/a 2010  0.502  0.506  0.507  0.643  0.700  n/a n/a 2011  0.485  0.488  0.490  0.621  0.676  n/a n/a 2012  0.477  0.480  0.482  0.611  0.665  n/a n/a 2013  0.469  0.472  0.473  0.600  0.653  n/a 0.983  2014  0.459  0.462  0.464  0.588  0.640  0.980  0.963  2015  0.459  0.462  0.463  0.588  0.639  0.978  0.962  2016  0.454  0.457  0.458  0.582  0.633  0.969  0.952  2017  0.447  0.450  0.451  0.572  0.623  0.953  0.937  2018  0.435  0.437  0.439  0.556  0.605  0.927  0.911  2019  0.427  0.430  0.431  0.547  0.595  0.912  0.896  2020  0.425  0.427  0.429  0.544  0.592  0.906  0.891  2021  0.403  0.406  0.407  0.516  0.561  0.859  0.845  2022  0.370  0.372  0.373  0.473  0.515  0.788  0.775   * Year price in effect   Payment Category Key:  OX Oxygen & oxygen equipment  (DME)  CR Capped rental  (DME)  IN Inexpensive/routinely purchased (DME)   FS Frequently serviced  (DME) SU DME  supplies  PO Prosthetics  & orthotics   SD Surgical  dressings  OS Ostomy, tracheostomy, and urological  supplies   PE Parental and enteral  nutrition TS Therapeutic Shoes   SC Splints and Casts  IL Intraocular Lenses inserted in a physicians office   IN, FS, OS and SU category deflation  factors=PO  deflation  factors   After deflation, the result must be increased by 1.7 percent and by the cumulative covered item update to complete the gap -filling (e.g., an additional .6 percent for a 2002 DME fee).  Note that when gap -filling for capped rental items, it is necessary to first gap -fill the purchase price then compute the base period fee schedule at 10 percent of the base period purchase price.   For used equipment, establish fee schedule amounts at 75 percent of the fee schedule amount for new equipment.  If within 5 years of establishing fee schedule amounts using supplier or commercial prices, the supplier or commercial prices decrease by less than 15 percent, CMS can make a one -time adjustment to the fee schedule amounts using the new prices.  The new supplier or commercial prices would be used to establish the new fee schedule amounts in the same way that the older prices were used, including application of the deflation formula of this section.   60.3.1 - Payment Concerns While Updating Codes  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)  The following instructions apply in situations where the CMS CO does NOT provide pricing guidance related to implementation of fee schedule for DMEPOS items and services.  Because a HCPCS code is new does not necessarily mean that Medicare payment on a fee schedule basis has never been made for the item and service described by the new code. In accordance with regulations at 42 CFR 414.110 and 414.236, if a new HCPCS code is  added, CMS and/or MACs make efforts to determine whether the item and service has a fee schedule pricing history. If there is a fee schedule pricing history, the previous fee schedule amounts for the previous code(s) are mapped to the new code(s) to ensur e continuity of pricing. When the code for an item is divided into several codes for the components of that item, the total of the separate fee schedule amounts established for the components must not be higher than the fee schedule amount for the original item. When there is a si ngle code that describes two or more distinct complete items (for example, two different but related or similar items), and separate codes are subsequently established for each item, the fee schedule amounts that applied to the single code continue to appl y to each of the items described by the new codes. When the codes for the components of a single item are combined in a single global code, the fee schedule amounts for the new code are established by totaling the fee schedule amounts used for the components (that is, use the total of the fee schedule amounts for the components as the fee schedule amount for the global code). When the codes for several different items are combined into a single code, the fee schedule amounts for the new code are established  using the average (arithmetic mean), weighted by allowed services, of the fee schedule amounts for the formerly separate codes.  60.4 - Process for Submitting Revisions to DMEPOS Fee Schedule to CMS  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)  The DME MACs identify instances where revisions to DMEPOS fees are needed and forward requests to CMS via email to the Division of Data Systems. The information must be contained in an ASCII file.  The requests must include a narrative description.   The following file specifications are 2003 examples, the actual file names may change each year:   Data Set Name  DMEREV1A.TXT  First Quarter Submission   DMEREV1B.TXT  Second Quarter Submission  DMEREV1C.TXT  Third Quarter Submission